Efficacy of implantoplasty in management of peri-implantitis: A systematic review

Abstract

Aim:

Peri-implantitis causes progressive loss of the supporting bony structure around the dental implant. Implantoplasty mechanically removes contaminated threads to achieve smoother implant surface thus reducing the bacterial load enabling fibroblastic growth to stimulate the healing effect. This Systematic review is done to appraise the outcome of implantoplasty on surface quality of Implant (roughness), biocompatibility of implants in peri-implantitis cases.

Settings and Design:

The Settings of the studies are major online databases like PubMed, Scopus, and Cochrane online library. The design of the current study is systematic review of published qualitative studies.

Materials and Method:

37 articles were identified for the present review and systematic electronic literature search was done from August 2022 to January 2023, via PubMed, Scopus, Medline, and The Cochrane Library (Wiley) databases [PRISMA guidelines]. In vitro studies on implantoplasty for peri-implantitis were included for the review. 2 examiners independently selected based on the inclusion criteria and recorded the necessary data.

Statistical Analysis Used:

Risk of bias assessment tool was evaluated with Newcastle Ottawa scale (NOS) and screened based on Selection, Comparability, and Outcome with the following categories: - maximum of 4, 2 and 4 points respectively. The observations were tabulated and analysed.

Results:

Among the 8 selected studies, two studies reported no statistical difference between implantoplasty and control, one study proposed carbide burs were better than diamond burs, another study also suggested multilaminar burs were better than diamond and carbide. The Newcastle Ottawa scale (NOS) score for the quality of the included studies ranged from 6 to 8. Two of the studies had score of 6 points, eight had 7 points and one had 8 points.

Conclusion:

Implantoplasty has been recommended as an efficacious treatment protocol for peri-implantitis that helps to diminish the inflammation and accompanied by a high success rate.

INTRODUCTION

Oral implants have proven to deliver an effective long-standing treatment option for the replacement of missing teeth.[1,2] Although this particular treatment option has high predictability and efficient outcome rates, meticulous constant maintenance and complication issues still do persist. Peri-implantitis is one such biological impediment that could result into detrimental effect on the long-term success of the implant procedure.[3] Peri-implantitis refers to a pathologic condition of the tissues surrounding the dental implants. It is typified by inflammation in the adjacent connective tissue resulting in progressive loss of supporting bony structure.[4] This condition occurs due to a disparity between the microbial load and the defense mechanism of the host or recipient.[5] The implant threads get exposed to the oral milieu and act as a favorable niche to bacterial adherence. This helps to promote the inflammatory process leading to progressive bone loss and in turn divulging more threads and permitting bacterial proliferation.[6] This inflammatory condition could result in failure and loss of the implant totally. Peri-implant disease can be categorized as peri-implant mucosal inflammation and peri-implantitis. The primary clinical features of this condition include increased probing depth, bleeding on probing, suppuration, injury to the adjacent bony structure, and finally, loss of the implant.[7]

Some of the risk factors that can be allied to the cause of peri-implantitis include chronic periodontitis cases, regular smoking, poor plaque control, and no preservation and poor maintenance after implant treatment.[8,9] The formation of biofilms and their composition is affected by surface properties inclusive of the surface topography, their chemical composition, and free energy on the implant surface. Such compounding factors such as surface roughness and various physiochemical characteristics make the dental implants vulnerable to bacterial adhesion and colonization.[10] Hence, the primary motive in treating a peri-implantitis case is the eradication of bacterial colonies, preservation of implant structure, enhanced esthetics, reduced bony defects, and finally, rejuvenation of lost bony structures. Re-osseointegration or healthy regeneration of the implant tissue requires actions such as control of inflammation, removal of bacterial biofilms in toto, and cleansing of the implant surface.[11] Surgical intervention that is carried out for peri-implantitis cases comprises open flap debridement, total elimination of granulation tissue, and decontamination of the exposed threads along with some resective procedures such as bone augmentation, and abolition of pocket are adapted to treat such cases.[12,13]

There are several methods for decontaminating the implant surfaces such as air-powder abrasion, ultrasonic and manual debridement with plastics or titanium curettes, implantoplasty, laser therapy, and titanium brushes. Certain chemical solutions applied are citric acid, hydrogen peroxide, cetylpyridinium chloride, tetracycline, ethylenediaminetetraacetic acid, chlorhexidine, etc., for the cleansing procedure.[14] Some other effective biofilm agents that have questionable responses included sodium bicarbonate and amino acid glycine.[15] Implantoplasty is done to smoothen the exposed implant threads with the help of diamond or carbide burs and thus favors diminishing the bacterial adherence thus facilitating fibroblastic growth and the healing process.[16,17]

Implantoplasty influences the mechanical properties and the technique resulting in excess metal debris at the surgical implant region. There is an increase in the activity of the inflammatory cells and cytokines cells, enhancement in the osteoclast activation, and abridged viability of gingival fibroblast when there is an accumulation of titanium particles and metal debris in the surrounding soft tissues.[18] This technique reduces the diameter and thickness of the implant. These factors along with bone loss owing to peri-implantitis upsurges the fracture risk of the implant.[19] It has been documented that unfavorable crown implant ratio, thinner implant that bends under high masticatory forces leading to fracture can be all due to severe bone loss.[20] Some studies have also reported that implantoplasty has the potential to imitate the platform switch concept in the recently adapted transmucosal surface by eliminating and polishing the implant threads and by lessening the diameter of the implant diameter in the most apical part of the exposed threads, which contacts the supporting bone.[21] There are many in vitro studies that have demonstrated the surface modification of rough implant discs (with diamond burs) failed to induce marked temperature increase or have an impact on surface biocompatibility with SaOs2 (cell line) osteoblast. The surface treatment augmented the hydrophilic nature of the surface that might be advantageous for re-osseointegration.[22,23] It has also been said that irrespective of the implantoplasty being executed or not, the longevity of implants treated for peri-implantitis was principally affected by the severity of bone loss present. Thus, it can be deduced that implantoplasty singularly cannot increase the probability of implant survival.[24] Therefore, this systematic review was planned with the aim to estimate and assess the outcome of implantoplasty on surface roughness and biocompatibility of implants in peri-implantitis cases.

MATERIALS AND METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [Figure 1].

Figure 1.

PRISMA Flowchart for the review. PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Eligibility criteria

A total of 37 articles were identified for potential review. The inclusion criteria were the clinical as well as preclinical studies involving implantoplasty to treat peri-implantitis. In vitro studies assessing the proprieties of the implant surface were also included. Studies which had either incomplete datum and other adjuvant procedures along with implantoplasty that were used for peri-implantitis were excluded from the study. Studies having Newcastle–Ottawa Scale (NOS)[25,26] scores of <7 were also excluded.

Focused question

• Does the use of implantoplasty increase the biocompatibility of implants or not?

Search strategy

Systematic electronic literature search was conducted over 6 months, from August 2022 to January 2023, of the PubMed, Scopus, Medline, and the Cochrane Library (Wiley) databases. Articles written in English were selected and reviewed. The search term or keywords applied were the following: ((“peri-implant disease” OR “peri-implantitis” OR “peri-implant mucositis” OR) AND (“implantoplasty” OR “mechanical modification of the implant” OR “implant surface debridement”)).

Study selection and data extraction

Two independent examiners (DG and SB) decided on the studies to be selected as per the inclusion criteria and relevant data were extracted by them. Irrelevant studies were eliminated based on the article title and the abstracts. The third and fourth authors (NP and DP) assessed the studies to rule out duplications. Then, the full-text article of all the remaining studies was analyzed. Any difference of opinion was discussed to reach a conclusion by consensus.

Risk of bias assessment

The risk of bias was assessed for this study using the NOS[25,26] and screened under the following criteria: selection, comparability, and outcome. The categories were given a maximum of 4 points, 2 points, and 4 points, respectively. The included studies were qualified as “Good,” “Fair,” and “Poor” quality based on the total NOS score they achieved. Those studies having a NOS score of more than 7 were considered good-quality studies.

RESULTS

Study selection

After the removal of duplicates and studies with incomplete data and failure of revival (out of the total 37 articles that were included in the review), only eight studies were selected for the present systematic review [Table 1].

Table 1.

Summary of review and results of various studies

Author, Year	Origin country	Groups	Methodology	Intervention	Observation methods	Results	Interpretation
Costa-Berenguer et al. (2018)[27]	Spain	Implantoplasty- 10 Control- 10	screw-shaped titanium dental implants with external connection.	Tungsten carbide burs, silicone carbide polishers: Brownie and Greenie	Scanning electron microscopy (SEM) confocal microscope	Mean time 10 mins 48 sec Surface roughness 0.2 +- 0.02 , 0.75 +-0.3	No statistical difference in max resistance force
Meier et al. (2012)[28]	Switzerland	Single group – 22	Straumann implants	11 different rotatory instruments	surface roughness measuring device	arithmetic mean roughness (rz) averaged roughness (ra) high coefficient of correlation (P<0.001)	the conical cutters had the lowest mean roughness values compared to spherical carbide cutters
de Souza Juniors et al. (2016)[29]	Brazil	3 groups (12)– and compared with controls	Implants	diamond, tungsten carbide, multilaminar	The temperature was measured by a data acquisition system, rugosimeter	Temperature changes- no significant difference. Between control and intervention Implant surface roughness statistically significant difference	multilaminar bur took less time
Ramel et al. (2016)[30]	Switzerland	6 different sequence groups	6. Forty-two one-piece implants were embedded in epoxy resin blocks with 6-mm rough implant surface exposed	G1:3 DB: + 2 SPBG G2:3 DB: + Arkansas G3: DB: G4:3 DB: +1 SPG G5:5 DB: G6:5 DB: + 1 SPG	Surface roughness measurement - Each implant was scanned with a stylus profilometer	G1: 0.32±0.14 µm G2: 0.39±0.13 µm G3:0.71±0.22µm G4: 0.59±0.19 µm G5: 0.98±0.30 µm G6: 0.75±0.26 µm CP: 0.1±0.01µm CR: 1.94±0.47 µm	final surface roughness and treatment duration, the use of rotary diamond burs in decreasing roughness, followed by AS, appears to be an optimal treatment option
Sahrmann et al. (2019)[31]	Switzerland	Two groups of 15	Titanium implants were placed in the position of both first maxillary molars in models exposing 6 mm of their surface.	: Bud-shaped diamond burs Conical silicon carbide stones	Operators’ Evaluation, Implant weight loss by precision scale and surface roughness measurement	G1: 0.76±0.14 µm G2: 0.38±0.15 µm Rz G1: 4.12±0.72 µm G2: 1.87±0.69 µm	a combination of abrasive stones and silicone polishers resulted in better gloss
Tawse-smith et al. (2016)[3]	New Zealand	Two groups 20 each machined and moderately roughened surfaces	grade IV titanium disks	Four different types of burs were used in the TPP: Shofu™ regular diamond, super-fne grit diamond, Brownie, Greenie	confocal laser scanning microscopy (CSLM),	Machined disc (G1) Before implantoplasty 4.00±0.52µm After implantoplasty 3.09±0.29µm Rough disc (G2) Before implantoplasty 4.50±0.4µm After implantoplasty 2.02±0.73µm	Surface roughness reduced in both groups
Octavi Camps Font et al. (2021)[19]	Spain	Three group (n=16) connection type. Half were controls	Screw-shaped titanium dental implants. Types: external hexagon, internal hexagon and conical.	The surface was moderately rough as a result of the sandblasting, acid-etching and anodizing techniques.	Implant wall thickness was recorded. All samples were subjected to a static strength test.	The mean wall thickness reductions varied between 106.46 and 153.75 µm.	Internal hexagon and conical connection implants seem to be more prone to fracture after implantoplasty.
Mehrnaz Behesti Maal et al. (2020)[17]	Norway	48 coins in 6 different rotatory bur sequence	On titanium coin	G1- CCB, red & white G2- CCB, red &white + AS G3- CCB, red & white + SC brownie+SC greenie G4- DSDC G5- DSDC + AS G6- DSDC + SC brownie + SC greenie	Immunostaining, Confocal microscopy	Surface roughness parameters were lower for the surfaces treated with experimental implantoplasty than for the SLA surface, and the sequence of carbide burs followed by silicone burs rendered the least rough surface of the test groups.	Carbide sequence better than diamond bur sequence

**AS: arkansas stone, DB: Diamond burs, SPBG: silicone polisher: Brownie & Greenie SPG: silicone polisher: Greenie, CCB: Carbide cutting burs, DSDC: Diamond sequence of decreasing coarseness, SC: Silicone cup

Studies characteristics

Out of the eight qualitative studies that were included here, three were from Switzerland, two from Spain, and one each from Brazil, New Zealand, and Norway. One study was done on titanium coins, one on titanium disks, and rest six were done on titanium implants of various companies and shapes. All eight studies were assessed on the terms of surface roughness which was considered one of the observational methods. Implant wall thickness was measured in one study, as well as operator observation and temperature change were observed in one study each. Seven out of eight studies were comparative studies and control group was present in three studies.

Maximum number of implants that were tested was “48” in two different studies by Camps-Font et al. and Beheshti Maal et al.[17] and least number of implants (22) tested were by Meier et al.

The main interventional element was diamond burs in five studies, tungsten carbide burs in four studies, silicon polisher in three studies, abrasive stones in two studies, unspecified rotatory instruments in two, and sandblasting, acid-etching, and anodizing technique in one study.

Two studies interpreted no statistical difference between implantoplasty and control, one study suggested carbide burs were better than diamond burs, and another study also suggested multilaminar burs were better than diamond and carbide. One another study found that diamond burs were better as compared to abrasive stones. Regarding the shape of the cutting instrument, it was found conical cutters had lowest mean roughness. Furthermore, for implant shape, it was found that internal hexagon and conical connection implants were more prone to fracture than external hexagon implants.

Risk of bias assessment

The NOS score for the quality of the included studies ranged from 6 to 8. Two of the studies had score of 6 points, eight had 7 points, and one had 8 points [Figure 2].

Figure 2.

NOS scores of the studies included

DISCUSSION

Peri-implantitis being an infectious disease surrounding the osseointegrated implants is characterized by loss of supporting bony tissues and inflammatory reactions including bleeding on probing. It has been reported to have a frequency in about 10% of implants and among 20% of patients after a period of 5–10 years postimplant treatment.[32] However, this prevalence varies contingent to the threshold of bone loss and/or probing depth. There are numerous clinical procedures to prevent and treat peri-implantitis cases, such as mechanical debridement, application of antiseptics or local/systemic antibiotics, and surgical interventions and regenerative measures.[33] There have been several researches that had attempted to combine and accumulate the data regarding such peri-implantitis cases in the past but have failed owing to the insufficient availability of information. Multiple efforts to combine the data of the available literature in a meta-analysis did not succeed in the past due to insufficient data.[34-37]

It has been documented that the adequate treatment strategy varies depending upon the case (whether it is mucositis adjacent to implant or peri-implantitis) and hence, no precise treatment method has been proven to be effective till date. Among the various number of treatment protocols for peri-implantitis, a comparatively good percentage of success rates have been documented with the procedure of implantoplasty.[38]

Inflammation of the peri-implant tissues, owing to bacterial colonization, becomes a matter of primary concern among dental practitioners. This bacterial colonization on the implant surface facilitates in the etiopathogenesis of peri-implantitis thus leading to progressive bone loss and poor prognosis of the patient.[39] Hence, the eradication of bacterial contamination from the implant surface and discontinuing the development of bone resorption mutually increase the rate of implant survival. Among the various techniques to bring increase the longevity of the implant, mechanical alteration of the surface done in implantoplasty proposes to eliminate the irregularities and attain a smooth surface comprising viable cells that impedes bacterial adhesion.[40]

Azzola et al.[41] concluded from their study that the efficacy of implantoplasty to decrease plaque adherence and manipulating the formation of biofilm could be considered an initial proof of concept. This study demonstrated that implantoplasty produces less growth of biofilm and less mature biofilm as compared to untreated implants. Geremias et al.[42] demonstrated that implantoplasty reduces the rate of bacterial proliferation. They deduced that surface modification of implants affected by peri-implantitis, (either by implantoplasty or chemical decontamination), favors decreased collection of biofilm as compared to that of mechanical debridement. However, it has been observed that despite the substantial decrease in roughness accomplished with implantoplasty procedure, very minor irregularities remain on the treated implant surface, thus, favoring further bacterial colonization.[27] Ramel et al.[30] have stated in their study that various implantation etiquettes can produce differences in the surface roughness of the treated implants. Surface roughness and the composition of biomaterials used play an imperative role in the development process of biofilm. Since the surface structures represent the quality of the soft-tissue closure and adaptation around the implant, they should be manipulated cautiously so as to avert infections. This theory is applicable to the oral milieu owing to the fact that dental plaque formation remains a constant menace for periodontitis and peri-implantitis, in vulnerable individuals.[23]

There are several chemical disinfectants such as ethylenediaminetetraacetic acid, tetracycline, hydrogen peroxide, and chlorhexidine that can be allied with implantoplasty procedure, however, their advantages with the protocol remain debatable.[43] Studies were done by Matarasso et al. (2014)[44] and Schwarz et al. (2017)[45] found that implantoplasty has enhanced clinical outcomes along with regenerative methods for peri-implantitis cases. These studies have reported a long-term good outcome of surgical resective/regenerative therapy or advanced peri-implantitis. However, not much of scientific evidence is available eliciting the advantages of the combination of implantoplasty and regenerative therapy and it has been observed that implantoplasty might not be related with to the biological and/or mechanical complications of the disease condition.[46]

Costa-Berenguer et al. (2018)[27] demonstrated in their study that implantoplasty cause a slight decrease in the inner diameter of the implant and there is no noteworthy alteration in the fracture resistance of the implant with standard diameter. Gehrke et al.[47] observed a 32% reduction in implant resistance after the implantoplasty procedure was performed. This study suggested that implant wear substantially reduces the resistance to external forces while applying nonaxial loading. This is achieved due to the architecture of implant-abutment interface which alters the clinical performance and fracture resistance of the implant system following implantoplasty.

The present systematic review included studies that did not report about the biological and/or mechanical complications and it was evident that the success rate of implantoplasty was high. Two of the studies in the present systematic review informed specifically about the individuals with a history or periodontal lesion or periodontitis.[21,24] The outcome and prognosis of implantoplasty procedures for the treatment of peri-implantitis rely on various local and systemic factors. Consequently, its result might vary from one individual to another with or without a vital risk factor.

Implantoplasty thus has suggestively shown to reduce the fracture strength of implants with standard diameter external connection when there is a reduction in the body diameter of the implant. In cases of advanced peri-implantitis, both resective and/or regenerative procedures and implantoplasty trailed by surface decontamination produce decent osseointegration. However, it is important to sustain an adequate maintenance phase after the therapy including oral hygiene maintenance and removal of surface biofilm. Surgical and implantoplasty procedures for peri-implantitis have depicted positive outcomes but long-standing research work is necessitated to attain the dependability and validity of the treatment protocols.

Few of the limitations that could affect the outcome of the study included insufficient numbers of research works and their low number of samples. Second, owing to the limited number of studies elucidating the parameters (surface roughness, biofilm formation, and biocompatibility) that were analyzed in this systematic review adequate information regarding the survival rate of the implants was not available. Third, since the literature that was published only in English language was considered for the present systematic review, there could be potential language bias in the information presented here.

CONCLUSION

Within the limitation of this systematic review, it can be concluded that:

1. Implantoplasty is recommended as a budding treatment option for peri-implantitis thus facilitating to reduce the inflammatory reaction followed by a high percentage success rate

2. Multilaminar burs or carbide burs with conical cutters were shown to cause less surface roughness

3. Implantoplasty has been found to reduce the fracture resistance of standard diameter dental implants with external connection when there is a reduction in the body diameter of the implant

4. Implants with internal hexagons and conical connections were found to be more prone to fracture when treated with implantoplasty.

However, stringent measures for good maintenance of the implant and the supporting structures are imperative for the long-term survival of the implant. It can be concluded that further research work is necessary, especially in clinical or in vivo situation, to predict the dependability, validity, and prognosis of the implantoplasty protocols.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.