Challenges of Gingival Surgery Approaches in the Treatment of Peri-Implantitis: A Systematic Review

ABSTRACT

Dental implants are an effective method to replace fixed and removable prostheses that were traditionally used. To properly treat peri-implantitis, early diagnosis, and continuous and timely patient monitoring are essential. This review was conducted to assess the challenges of gingival surgery approaches in the treatment of peri-implantitis to help dentists in this field. A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted between 2021 and the end of 2024. Two independent reviewers screened the studies based on the abstracts of each of them. In case of discrepancies, a third reviewer also judged the disagreements. Data from the articles were extracted in designed forms so that the key findings of each study could be discussed, including the name of the first author, year of publication, and key findings. Based on the search keywords 541, studies were found from the datasets. 498 studies were screened using title and abstract evaluation, and finally 14 articles were included in the study. Finally, we have briefly reviewed the challenges of gingival surgery approaches in the treatment of peri-implantitis. It is concluded that successful management of peri-implantitis requires careful clinical assessment, appropriate treatment planning, and selection of effective surgical techniques. Regular periodontal care, careful control of soft and hard tissues, and patient participation in oral hygiene play a key role in prevention and treatment.

INTRODUCTION

To replace the missing primary teeth of humans, the developed methods of dental implants have been able to lead to aesthetics, good quality of life, and high satisfaction of users.[1] Dental implants are an effective and efficient method to replace fixed and removable prostheses that were traditionally used to compensate for the use of teeth.[2] The ten-year durability of dental implants, which is about 92.8 to 97.1%, has made it an acceptable method.[3] However, it has brought a major challenge called peri-implantitis. In peri-implantitis, the tissues around the implant become inflamed and the surrounding bones gradually deteriorate, which causes implant rejection.[4] In addition, it can destroy both soft and hard tissues.[1] Among the important symptoms of peri-implantitis are asymptomatic bone resorption, bleeding on probing, and swelling of the surrounding tissue.[3] Peri-implantitis is common in 11.2 to 22% of people with implants, which is considered a complex biological complication in this regard.[2] To properly treat peri-implantitis, early diagnosis and continuous and timely patient monitoring are essential.[3,4] For this purpose, its diagnosis can be based on a probe depth of more than six millimeters, bleeding, or pus discharge.[1] In order to implement the treatment of peri-implantitis in early cases, non-surgical methods such as laser and drug therapy[4] can be used, focusing on oral hygiene. However, in other cases, the need for surgical intervention to repair damaged tissues is inevitable,[1] which has higher effectiveness[2] and can lead to a repair of about 2–3 millimeters of bone.[1] However, this measure of healing can vary depending on factors such as poor oral hygiene, smoking, and periodontal disease. Surgical procedures include implantoplasty and guided bone regeneration.[4] The main challenge in the treatment of peri-implantitis is to debride the infected implant surface and eliminate deep peri-implant pockets.[5] Limited predictability of soft and hard tissue reconstruction outcomes, soft tissue recession, disease recurrence, and lack of valid scientific evidence can be considered as challenges in the surgical treatment of peri-implantitis. On the other hand, the patient’s condition, the type of defect, and functional and aesthetic expectations can be considered as considerations in the selection of the treatment method.[5] There are important challenges in this field that can affect the efficacy and selection of treatment, therefore, this review was conducted to assess the challenges of gingival surgery approaches in the treatment of peri-implantitis to help dentists in this field.

METHODS

This is a review that was designed by the PRISMA guidelines. The inclusion of studies in this review was based on the following criteria:

Population: Types of studies conducted on humans and animals.

Intervention or exposure: gingival surgery.

Outcome: Challenges related to the treatment approach to peri-implantitis.

Study design: Types of clinical trials, observational studies, case studies.

Language: English.

Time: 2021–2024.

Exclusion criteria for this review included the following: Studies that did not assess the treatment challenges associated with peri-implantitis or the original article could not be accessed. In addition, studies that evaluated non-surgical treatment methods were excluded from this review.

Search strategy

A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted between 2021 and the end of 2024 using the following keywords; peri-implantitis, peri-implant inflammation, gum surgery, gingival surgery, mucogingival surgery, challenges, complications. They were modified using Boolean operators AND and OR.

Selection and screening of studies

Two independent reviewers screened the studies based on the abstracts of each of them. In case of discrepancies, a third reviewer also judged the disagreements.

Data extraction

Data from the articles were extracted in designed forms so that the key findings of each study could be discussed, including the name of the first author, year of publication, and key findings.

RESULTS

Published studies between 2021 and the end of 2024 were considered. Based on the search keywords 541, studies were found from the datasets. 498 studies were screened using title and abstract evaluation, and finally, based on Figure 1, 14 articles were included in the study.

Figure 1.

PRISMA flowchart for selecting of the literature related to this systematic review

We reviewed each of the relevant articles using bias and quality assessment tools. It can be said that all studies had no problem being included in this review. Finally, based on the contents of the abstracts of the articles and their full texts, we have briefly reviewed the challenges of gingival surgery approaches in the treatment of peri-implantitis, which we will discuss in the discussion section of this article.

DISCUSSION

Several studies have examined the errors, challenges, and effective treatment approaches in the management of peri-implantitis. Roccuzzo et al.[6] demonstrated that factors such as poor patient selection, poor treatment planning, and poor oral hygiene can lead to peri-implantitis. This study emphasizes the importance of choosing the appropriate surgical technique and careful management of soft and hard tissues to achieve optimal results. Sangkhamanee and Teparat-Burana[7] reported the successful treatment of labial soft tissue fenestration with bone defect. In this case, the use of mucogingival surgery and free connective tissue grafting were effective methods, which maintained the stability and health of the peri-implant tissues after two years.

A study by Abdulwahab[8] showed that both connective tissue graft (CTG) and collagen matrix graft (CMX) increase the thickness of the peri-implant soft tissue, but they have differences in the pattern of vascularization. CTG may provide better vascularization due to the presence of living cells and growth factors, while CMX acts as a scaffold for vascular growth. Although CMX is less effective in increasing soft tissue thickness than CTG, its advantages, such as reduced need for tissue harvesting from the donor area and reduced surgical complications, make it a suitable option. The choice of treatment method should be tailored to the patient’s condition. Also, the study by Apatzidou[9] points to the negative role of smoking in implant treatment. Smoking increases the likelihood of bone loss and tooth loss by impairing host immunity and reducing tissue healing. This evidence highlights the importance of quitting smoking to improve treatment outcomes. Chandrasekar et al.[10] showed that periodontal and peri-implant microsurgery using microscopic instruments and precise techniques helps reduce surgical invasiveness, improve treatment outcomes, and increase patient satisfaction. Crauste et al.[11] also reported the success of guided surgery for autogenous soft tissue grafting with an increase of 2.5 mm in the width of keratinized tissue. These approaches offer new solutions for periodontal treatments by improving precision, reducing complications, and increasing surgical comfort.

Various studies have addressed the challenges and strategies associated with the treatment of peri-implantitis and the management of soft tissue around implants. A study by Pedercini et al.[12] presented a decision tree for soft tissue surgical management that focused on assessing the thickness and width of keratinized tissue. Qiu et al.[13] compared two methods, porcine collagen matrix (XCM) and free gingival grafting (FGG), and showed that XCM had shorter surgical time and less pain, but FGG provided better results in increasing mucosal thickness. A study by Quispe-López et al.[14] and Ripoll et al.[15] reviewed new surgical techniques and graft materials such as CTG and DFGG. These findings highlight the importance of selecting the appropriate materials for optimal soft tissue management and achieving aesthetic outcomes. These studies indicate that the selection of the appropriate surgical technique and materials, taking into account clinical characteristics, is crucial for the successful treatment of peri-implantitis, moreover they emphasize the importance of combining expert knowledge, precise surgical techniques, and patient participation in the prevention and management of peri-implantitis.

Limitations of this study include the limited number of samples and the variety of clinical conditions. It is suggested that future research investigate the long-term effects of treatments and further compare surgical methods, and evaluate the role of individual factors such as general health status and oral hygiene in the treatment of peri-implantitis.

CONCLUSION

It is concluded that successful management of peri-implantitis requires careful clinical assessment, appropriate treatment planning, and selection of effective surgical techniques. Regular periodontal care, careful control of soft and hard tissues, and patient participation in oral hygiene play a key role in prevention and treatment. The use of novel techniques such as connective tissue grafting and collagen matrix, combined with imaging technologies, can ensure improved clinical outcomes and reduced complications, and enhance treatment strategies.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.