Surgical Treatment of Periimplantitis With Augmentative Techniques

Clinical and radiographic outcomes of a combined surgery approach to treat peri-implantitis

Peri-implant infra-bony defects are difficult to treat, and data on the management of peri-implantitis are lacking. The aim of this study was to evaluate the effect of a combined surgical approach to manage peri-implantitis: implantoplasty with xenogeneic bone grafting and a concentrated growth factor membrane. Two independent examiners analysed the medical records and radiographs taken before surgery and at the last follow-up. Data were analysed at the implant level; some patient-level data (age, sex, smoking habit) were also considered. Linear regression analysis with generalized estimating equations (GEE) was used to explore the effect of variables of interest (including marginal bone level (MBL)) on implantitis treatment success and resolution rates. The effect of the prosthesis type on postoperative clinical and radiographic parameters was also explored by GEE, with adjustment for age, sex, tooth site, location, follow-up duration, and implant length (model IV including all). Thirty patients with 72 implants were investigated. The implant survival rate was 100% over a mean observation period of 3.3 years (range 2-11 years). The treatment success rate (bone loss <0.5 mm, no bleeding on probing (BOP), no suppuration, probing depth (PD) < 5 mm) was higher in females than males (50% vs 19.0%; P = 0.008). At the last postoperative follow-up, the MBL (1.51 ± 1.07 vs 4.01 ± 1.13 mm), PD (3.61 ± 0.84 vs 6.54 ± 1.01 mm), and BOP (23.38 ± 23.18% vs 79.17 ± 15.51%) were significantly reduced when compared to pre-surgery values (all P < 0.001). Furthermore, a significantly higher PD reduction (β = -1.10 mm, 95% confidence interval -1.97 to -0.23 mm, P = 0.014) was observed for implants with a single crown than a full-arch prosthesis (GEE model IV). Preliminary clinical and radiographic data indicate that implantoplasty in combination with surgery could be an effective treatment option for peri-implantitis.

Analysis of risk factors for early crestal bone loss in osseointegrated, submerged implants prior to restoration

BACKGROUND

Evidence on the etiology behind bone loss around submerged, prosthetically nonloaded implants is still limited. The long-term stability and success of implants with early crestal bone loss (ECBL), especially when placed as two-stage implants, is uncertain. Hence, the aim of this retrospective study is to analyze the potential patient-level, tooth- and implant-related factors for ECBL around osseointegrated, submerged implants, before restoration as compared with healthy implants with no bone loss.

METHODS

Retrospective data were collected from patient electronic health records between 2015 and 2022. Control sites included healthy implants with no bone loss and test sites included implants with ECBL, both of which were submerged. Patient, tooth and implant level data were collected. ECBL was assessed using periapical radiographs obtained during implant placement and second-stage surgeries. Generalized estimating equation logistic regression models were used to account for multiple implants within patients.

RESULTS

The total number of implants included in the study was 200 from 120 patients. Lack of supportive periodontal therapy (SPT) was shown to have nearly five-times higher risk of developing ECBL and was statistically significant (p < 0.05). Guided bone regeneration (GBR) procedures before implant placement had a protective effect with an odds ratio of 0.29 (p < 0.05).

CONCLUSIONS

Lack of SPT was significantly associated with ECBL, while sites that received GBR procedures prior to implant placement were less likely to exhibit ECBL. Our results underscore the importance of periodontal treatment and SPT for peri-implant health, even when the implants are submerged and unrestored.

Clinical efficacy of guided bone regeneration in peri-implantitis defects. A network meta-analysis

Guided bone regeneration (GBR) at peri-implantitis-related bone defects involves the placement of bone-filler particles in the intrabony defects and the application of a barrier membrane. The efficacy of different GBR-supported reconstructive measures as well as their potential superiority compared to non-GBR-supported treatment strategies for bone defects at peri-implantitis sites, however, remains unclear. Therefore, this analysis was designed to evaluate the long-term (≥12 months) clinical efficacy of GBR-supported reconstructive surgical therapy for peri-implantitis-related bone defects. In terms of resolving inflammation, the implementation of GBR protocols applying xenogenic bone substitutes yielded a higher reduction of bleeding on probing and probing depth value compared to the GBR protocol applying autogenous bone. Furthermore, for the changes in bleeding on probing and probing depths, GBR approaches using xenogenic bone showed superiority over the non-GBR treatments. Xenogenic bone with or without a barrier membrane was associated with improved radiographic bone levels and less soft tissue recession compared to the use of a GBR protocol implementing autogenous bone. Nonetheless, when interpreting this findings, the limited number of available studies with low to serious risk of bias and the short follow-up periods limited to 12 months should be considered.

Utilization of Low-Magnitude High-Frequency Vibration (LMHFV) as an Aid in Treating Peri-Implantitis: Case Presentations

Peri-implantitis is an inflammatory process initiating in the soft tissue and then progressing to the hard tissue surrounding dental implants leading to loss of osseous support and potential loss of the implant if not identified early in the process. This process initiates in the soft tissue, which become inflamed spreading to the underlying bone leading to decreases in bone density with subsequent crestal resorption and thread exposure. In the absence of treatment of the peri-implantitis, the bone loss at the osseous implant interface progresses with inflammatory mediated decrease in the bone density that moves apically, eventually leading to mobility of the implant and its failure. Low-magnitude high-frequency vibration (LMHFV) has been shown to improve bone density, stimulate osteoblastic activity, and arrest progression of peri-implantitis with improvement of the bone or graft around the affected implant with or without surgery as part of the treatment. Two cases are presented using LMHFV to augment treatment.

Why is there a lack of evidence regarding errors and complications in periodontal and implant therapy?

The occurrence of errors, complications, and adverse effects may occur as a consequence of single or multiple events related to the clinician and/or patient. Apparently, the amount of dental literature on these undesirable outcomes has not been as prolific as that obtained for conventional primary periodontal outcome measures. This review explores the potential reasons for the lack of studies reporting on errors and complications in periodontal and implant therapy, as well as other noteworthy methodological aspects, to enlighten their impact on the selection of the best (or most appropriate) "gold standard" periodontal/implant-related treatment options, and on the overall decision-making process. The following points were addressed: (a) the importance of reporting errors and complications in clinical research; (b) the adequate reporting of errors and complications in periodontology and dental implantology; and (c) efficacy trials vs effectiveness studies and their impact on the assessment and report of periodontal and implant treatment-related risks and complications.

The use of autogenous tooth bone graft is an efficient method of alveolar ridge preservation - meta-analysis and systematic review

BACKGROUND

Ridge resorption following tooth extraction may be reduced by alveolar ridge preservation (ARP). Previous randomized clinical trials and systematic reviews have suggested that autogenous tooth bone graft (ATB) can be an effective alternative material for ARP. However, the results are heterogeneous. Therefore, our research aimed to evaluate the efficacy of ATB in ARP.

METHODS

A systematic search was conducted in Cochrane Library, Embase, MEDLINE and Scopus for studies published from inception to 31 November 2021. We searched searched for randomized, non-randomized controlled trials and case series reporting on ATB use for ARP. The primary outcome was the ridge width difference pre- and post-surgery, measured in millimetres (mm) measured on CBCT (cone beam computed tomography). The secondary outcomes were the histological results. We followed the PRISMA2020 recommendations for reporting our systematic review and meta-analysis.

RESULTS

The analysis included eight studies for the primary and six for the secondary outcomes. The meta-analysis revealed a positive ridge preservation effect with a pooled mean difference ridge width change of -0.72 mm. The pooled mean residual graft proportion was 11.61%, and the newly formed bone proportion was 40.23%. The pooled mean of newly formed bone proportion was higher in the group where ATB originated from both the root and crown of the tooth.

CONCLUSIONS

ATB is an effective particulate graft material in ARP. Complete demineralization of the ATB tends to decrease the proportion of newly formed bone. ATB can be an attractive option for ARP.

TRIAL REGISTRATION

The study protocol was registered on PROSPERO (CRD42021287890).

The efficacy of bone reconstructive therapies in the management of peri-implantitis. A systematic review and meta-analysis

AIM

To evaluate the efficacy of bone reconstructive procedures for the reduction of probing pocket depth (PPD), bleeding on probing (BOP), and suppuration in peri-implantitis-related bone defects at ≥12-month follow-up.

MATERIALS AND METHODS

Three databases were searched for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared bone reconstructive therapies to access flap surgery (AFS) (Focused Question-FQ 1), and RCTs, CCTs, and prospective case series that assessed the efficacy of reconstructive therapies (FQ 2). Meta-analysis was performed for FQ1 when more than three studies were identified, while for FQ2 a network was drawn based on RCTs with common treatment arms.

RESULTS

Seven RCTs were identified for FQ1 while five RCTs and six prospective case series for FQ2. There was no significant difference in PPD change between AFS and reconstructive surgery (-0.387; p = .325) at 12 months. Furthermore, no clear differences in terms of PPD and BOP changes resulted from the different reconstructive therapies included in the network. Only a small percentage of treated cases with any modality achieved peri-implantitis resolution, as defined by different composite outcomes.

CONCLUSIONS

Reconstructive surgery does not offer significant improvements in peri-implant clinical parameters as compared to AFS at 12 months. It was not possible to establish a hierarchy of efficacy among the different biomaterials employed for reconstructive surgery.

Surgical interventions for the treatment of peri-implantitis

BACKGROUND

Peri-implantitis constitutes one of the most frequent late dental implant complications. The disease is initiated by bacterial infection; therefore, anti-infective peri-implantitis treatment strategies are required to arrest the progressive marginal bone loss and maintain the affected implant in function. Although nonsurgical treatment strategies appear to be of limited predictability, treatment outcomes have been frequently improved following surgical interventions.

PURPOSE

The present narrative review describes various surgical peri-implantitis treatment modalities, with respect to their indications, performance, and effectiveness.

MATERIALS AND METHODS

The present narrative review considered the most relevant studies in the field published in the English language.

RESULTS

Surgical peri-implantitis treatment approaches can be categorized as nonreconstrucive therapy, reconstructive therapy, and combined therapy (ie, reconstructive and resective therapy). In addition to disease resolution, reconstructive approaches also seek to regenerate the bone defect and achieve reosseointegration.

CONCLUSIONS

The severity of the disease, the regenerative potential of the defetc and esthetic demands of the patient are the factors determining the surgical peri-implantitis treatment modality.

Effects of implant surface mechanical instrumentation methods on peri-implantitis: An in vitro study using a circumferential bone defect model

Background/purpose

Although several mechanical and chemical debridement techniques have been reported for the management of peri-implantitis, there is no consensus on the most effective method at present. This in vitro study aimed to examine the effects of different mechanical instrumentation techniques on the debridement of hard calcified materials, which are present on the implant surface, as well as the effect of the defect morphology.

Materials and methods

From a total of 15 implants, five each were assigned to one of three decontamination groups (Rotary titanium brush [Ti], tricalcium phosphate air powder abrasive treatment [Air], and titanium ultrasonic scaler [US] groups); the exposed hydroxyapatite (HA)-coated portion was divided into three 1-mm sections (coronal, middle, and apical). The residual-HA of each portion was measured using a digital microscope.

Results

The overall percentage of residual HA coating was significantly lower in the US group than in the Ti or Air groups (p < 0.01). The percentage of residual HA in the coronal portion was significantly lower in the Ti and US groups than in the Air group (p < 0.05 and p < 0.01, respectively). The percentage of residual HA in the middle portion was significantly lower in the US group than in the Air group (p < 0.01). The percentage of residual HA in the apical portion was significantly lower in the Ti group than in the Air or US groups (p < 0.01).

Conclusion

Ti and US were more effective for shallow defects, whereas US was more effective for deeper defects.

Surgical therapy of peri-implantitis

Peri-implantitis is caused by a bacterial challenge; therefore, anti-infective treatment strategies should be employed to manage the disease. As nonsurgical approaches demonstrate limited efficacy in most cases of peri-implantitis, surgical interventions are often required. Treatment outcomes improve following access flap surgery, with or without adjunctive resective and/or augmentation measures. Whereas nonaugmentative therapies (ie, access flap surgery and resective techniques) primarily aim to resolve inflammation and arrest further disease progression, augmentation approaches also seek to regenerate the bony defect and achieve reosseointegration. Currently, limited evidence supports the superiority of augmentative surgical techniques for peri-implantitis treatment over nonaugmentation methods, and human histologic evidence for reosseointegration is sparse. For patients involved in regular postoperative maintenance programs, success of peri-implantitis surgical treatment based on various definitions of success was obtained in over half of the cases after 5-7 years. Despite surgical treatment, cases of further disease progression that required retreatment or led to implant loss were reported.

Papilla preservation and minimally invasive surgery for the treatment of peri-implant osseous defects. Clinical and radiographic outcomes of a 5-year retrospective study

OBJECTIVES

Evaluate in a case series the clinical applicability of a regenerative approach for treatment of peri-implant lesions based on papilla preservation flaps (PPF) and minimally invasive surgery (MIST).

MATERIAL AND METHODS

Twenty-one deep peri-implant defects in 21 patients were surgically accessed applying PPF and MIST. The exposed implant surface was decontaminated with the sequential application of mechanical devices and chemical agents. Bone substitutes alone or in combination with a collagen barrier were applied, according to the anatomy of the peri-implant lesion. Clinical and radiographic measurements were collected at baseline, post-surgery, 1 and 5 years.

RESULTS

Primary wound closure was obtained in 100% of the sites and maintained in 90% of the sites at 1 week. Bleeding on probing (BOP) was reduced from 100% at baseline to 28.6% at 1 year and to 42.8% at 5 years. The 1-year pocket reduction was 3.9 ± 1 mm. Residual probing depths (PD) were 4.1 ± 0.9 mm. PD remained stable up to 5 years. The radiographic bone gain was 2.5 ± 1.2 mm (mesial) and 2.5 ± 1.1 (distal) at 1-year and 2.3 ± 1.3 mm (mesial) and 2.6 ± 1.4 mm (distal) at 5 years. The radiographic resolution of the defect was 70.4% ± 19% (mesial) and 70.2% ± 22% (distal) at 1 year and 64.2% ± 21% (mesial) and 67.7% ± 21% (distal) at 5 years. All implants survived up to 5 years. A composite outcome of disease resolution shows consistent 1-year clinical improvements at all the treated sites and substantial 5-year stability.

CONCLUSIONS

PPF and MIST can be successfully applied for the regenerative treatment of peri-implant defects.

Peri-Implantitis Regenerative Therapy: A Review

Simple Summary

Regenerative therapies are one of the options to treat peri-implantitis diseases that cause peri-implant bone loss. This review reports classic and current literature to describe the available knowledge on regenerative peri-implant techniques.

Abstract

The surgical techniques available to clinicians to treat peri-implant diseases can be divided into resective and regenerative. Peri-implant diseases are inflammatory conditions affecting the soft and hard tissues around dental implants. Despite the large number of investigations aimed at identifying the best approach to treat these conditions, there is still no universally recognized protocol to solve these complications successfully and predictably. This review will focus on the regenerative treatment of peri-implant osseous defects in order to provide some evidence that can aid clinicians in the approach to peri-implant disease treatment.

Regenerative Surgical Therapy of Peri-implantitis: An Umbrella Review of Answered/Unanswered Questions and Future Perspectives

Purpose: To systemically summarize current knowledge about regeneration of peri-implant defects based on available systematic reviews.

Materials and Methods: A systematic search for review articles published between 2010 and 2020 in four databases was conducted. Only systematic reviews and meta-analyses were included. Based on the available literature, five questions of clinical importance on indication for regenerative approaches, surgical technique, methods of decontamination, outcome of therapy and adjunctive use of biological factors were formulated and answered.

Results: The electronic search resulted in 312 studies, from which 264 studies were published between 2010 and 2020. Finally, 18 systematic reviews and one consensus report were chosen. Data of the included studies were based on 58 to 840 implants. Data on over 4.904 implants were assessed. From the 19 studies that were included, 15 assessed the outcome of regenerative therapy; three, the surgical protocol of regenerative therapy; two, the use of laser in regenerative therapy; and one, the additional use of growth factors in regenerative peri-implant therapy. Three studies assessed more than one topic.

Conclusions: In general, a partial bone fill can be expected in 85% of regenerative procedures. Regeneration leads to a mean of 57% of greater bone fill, compared to open flap surgery only. Defect configuration plays a crucial role in the outcome, whereas the role and extent of benefit of different surgical protocols are still not clear.