Abstract:
The following consensus report is based on four background reviews (Keeve et al., Implant Dent 2019 28(2): 177–186; Ramanauskaite et al., Implant Dent 2019 28(2): 187–209; Koo et al., Implant Dent 2019 28(2): 173–176; Sculean et al., Implant Dent 2019 210–216). The surgical treatment of peri-implantitis is indicated in the cases where the first choice of treatment, the non-surgical one, failed with recurrence of bleeding and suppuration. The aim of this review was to systematically screen the literature for possible surface decontamination techniques and material during surgical treatment, the surgical regenerative and non-regenerative treatments of peri-implantitis, radiological and clinical outcomes, the importance of the presence of fixed and or keratinised peri-implant gingiva, and to determine predictable therapeutic options for the clinical surgical management of peri-implantitis lesions. Existent clinical, radiographic and microbiological data do not favour any decontamination approaches and fail to show the influence of a particular decontamination protocol on surgical therapy. Using implantoplasty in surgical non-regenerative treatment leads to a significant decrease in bleeding on probing and probing depth, and may result in improvement of clinical and radiographic parameters, up to 3 years after surgery compared with mechanical debridement alone. Surgical augmentative peri-implantitis therapy resulted in improved clinical and radiographic treatment outcomes compared with the baseline in the majority of studies with 6 months to 7–10 years of follow-up. There is no evidence to support the superiority of a specific material, product or membrane in terms of long-term clinical benefits. The best treatment modality to improve the width of keratinised attached mucosa and bleeding and plaque scores, and to sustain the peri-implant marginal bone level, is the use of an apically positioned flap combined with a free gingival graft.
Key words: Peri-implant diseases, peri-implantitis, surgical therapy, surface decontamination, implantoplasty, resective treatment, bone graft, regenerative surgery, soft tissue graft, apically positioned flap, submerged treatment, non-submerged treatment, maintenance, supportive care
INTRODUCTION
Peri-implant diseases are defined as a ‘collective term for inflammatory reactions in the tissues surrounding the implants’, whereas peri-implantitis was introduced as an inflammatory process on hard and soft tissue resulting in pocket formation and loss of supporting bone1. The wide range in prevalence rates is probably attributed to differences in definitions, study population, and implant micro- and macrostructures. Therefore, an effective strategy for treating peri-implantitis is required to prevent loss of bone, function, aesthetics, and at least prevent loss of the implant itself2., 3..
Several clinical protocols for treatment of peri-implantitis have been proposed, including mechanical debridement, the use of antiseptics and local or systemic antibiotics, surgical access, and regenerative or resective surgical procedures1., 2., 3., 4.. In this working group, a total of four topics was selected to reflect, based on reviews and clinical/experimental trials, the current level of evidence and to provide answers to critical questions related to the surgical treatments of peri-implantitis. These questions in particular address radiological and clinical outcomes, and determine predictable therapeutic options for the clinical surgical management of peri-implantitis lesions. These topics include surgical non-augmentative treatment5, surgical augmentative treatment6, effective decontamination of the implant surface7, and the correction of peri-implant soft tissue8. The answers to the questions are based on the four position papers presented at the FDI World Dental Federation consensus meeting on peri-implantitis in May 2018.
The first paper focuses on surgical non-augmentative treatment of peri-implantitis. Briefly, it was concluded that the clinical peri-implant parameters pocket depth (PD) and bleeding on probing (BOP) improved after access apical surgery only, surface decontamination with chlorhexidine (CHX) and/or cetylpyridinium chloride, but no potential benefits of systemic antibiotics over 3 years were reported5. The clinical parameters improved significantly, especially in studies performing implantoplasty. Implantoplasty (diamond/Arkansas burs + silicone polishers) as an adjunct to open flap debridement with bone recontouring and apical flap repositioning has been shown to achieve greater immediate suppression of anaerobic bacteria on the implant surface and result in better BOP and PD scores, but higher mean mucosal recessions, compared with the control group in which persistent active signs of peri-implant inflammation recurred in all patients after 24 months5.
The second paper discusses the surgical treatment of peri-implantitis with augmentative techniques6. Most of the described cases presented intrabony peri-implant defect configurations. A variety of bone replacement materials were applied (autogenous bone, alloplastic bone filler and xenograft, titanium granules) with and without resorbable or non-resorbable membranes3., 4., 9., 10.. Augmentative peri-implantitis therapy was shown to result in statistically significant improvements in BOP and PD values compared to baseline. Although autogenous bone grafts are still the gold standard in augmentation surgery, significantly higher radiographic bone level gain was obtained in the short term with the use of xenograft in comparison to autogenous bone, of course due to the intensive radio-opacity of xenograft. Increased radiographic bone defect fill was detected in the sites treated with the porous titanium granules compared with xenograft, while the clinical outcomes did not differ between the groups. Despite the successful clinical and radiographic clinical performance of augmentative therapies, cases of implant loss, disease recurrence and further progression were reported. Exposure of the barrier membrane, fistula or sequester formation were reported in 58.6% of cases when barrier membranes (resorbable and non-resorbable) were used6.
The third paper addresses the decontamination of the implant surface during the surgical treatment of peri-implantitis7. Mechanical, chemical or photodynamic measures along with laser therapy have attempted to eliminate infection, resolve inflammation, and render the surface conducive to bone regeneration and possible re-osseointegration. All materials and tools used for surface decontamination such as CHX, citric or phosphoric acid, all kinds of laser, in the case of non-submerged surgical treatment of peri-implantitis failed to show any clinical difference in comparison to saline control over the long term regardless of the implant surface7. This is due to direct recontamination by the oral flora.
The fourth paper focuses on soft tissue management as part of the surgical treatment of peri-implantitis8. The presence and thickness of keratinised and/or attached mucosa (KAM) as related to the health and long-term stability of peri-implant tissues has been controversially reported in the literature. However, at present it is generally accepted that the presence of an adequate width of KAM around dental implants is associated with less plaque accumulation and lower incidence of peri-implant infections11., 12., 13.. Soft tissue augmentation procedures seem to be beneficial to establish and maintain peri-implant health. Statistically significantly better outcomes for gain in keratinised tissue width, lower bleeding (BOP, gingival index) and plaque scores, as well as less recession and marginal bone changes were observed in patients treated with the apical reposition flap (ARF) in conjunction with a free gingival graft as compared with control groups where no grafting was performed8. The following section summarises the main findings on this topic.
Summary statements in the areas of surgical non-augmentative treatment, surgical augmentative treatment, implant surface decontamination and soft tissue management, as developed by working group 4 during the FDI consensus meeting.
SUMMARY STATEMENTS IN THE AREAS OF SURGICAL TREAMENT OF PERI-IMPLANTITIS, AS DEVELOPED BY WORKING GROUP 4 DURING THE FDI CONSENSUS MEETING
Surgical non-augmentative treatment
In which indications is surgical non-augmentative treatment effective?
Surgical non-augmentative modalities treating peri-implantitis can reduce the amount of inflammation in the short term, but seem to have limited effectiveness in the long term. Implant surface modifications can lead to a decrease in BOP and PD, and may result in improvement of clinical and stable radiographic parameters. Application of systemic antibiotics, chemical compounds or diode laser will not lead to clinical or radiographic long-term improvements. Surgical non-augmentative treatment of peri-implantitis is indicated for supra-crestal bone defects (horizontal bone loss) with exposed threads in aesthetically non-demanding areas based on patient needs and satisfaction. Even in cases of peri-implant mucositis, it can be advisable to perform an access flap for proper mechanical and chemical decontamination (i.e. additional removal of cement remnants) of the implant surface.
Do we need to perform ‘implantoplasty’?
The non-augmentative treatment concept involves reduction or elimination of pathological peri-implant pockets, the apical positioning of a mucosal flap, or recontouring bone with or without implant surface modification. In case of modifications of implant surfaces the rough design should be removed and polished by using diamond or carbide burs and metal polishing instruments with irrigation. However, a concern of the remaining titanium particles should be addressed.
Do we need to remove the suprastructures?
The suprastructure may affect the quality of implant decontamination, modification and flap design, and possibly the measurement of clinical parameters. If possible, it is strongly recommended to remove the suprastructure during surgical intervention and potentially adapt for better oral hygiene ability.
Surgical augmentative treatment
What are the indications for augmentative peri-implantitis surgery?
Recurrence after non-surgical treatment and presence of intra-bony peri-implant defects.
Which material should be used?
Autogenous bone material is still the gold standard, but also different bone substitutes can be used successfully. There is no evidence in the literature to support the superiority of a specific material, product or membrane in terms of long-term clinical treatment benefits.
Is primary closure preferable for a good outcome?
When feasible, submerged post-operative wound closure healing is recommended in order to allow a protected physiological healing.
Decontamination in surgical treatment of peri-implant diseases
What is the aim of mechanical debridement during surgery and which instruments can be used?
Plaque, calculus, excess cement and inflamed tissues should be removed.
Metal instruments (stainless steel, titanium), ultrasonic devices with various tips, air polishing units (i.e. air-flow) and titanium brushes can be used.
Is there any risk of emphysema/embolism using air polishing devices?
Although the risk of complications is relatively low, a proper utilisation technique of air-polishing systems is highly recommended in order to avoid risks: the device should project only on the implant surface and avoid the bone. Comprehensive follow-up examination should be employed to provide optimal care for the patient.
What kind of chemical/antimicrobial agents can be used?
Various options of decontamination (saline, citric acid, 3% H2O2, iodine solutions 24%, CHX 0.2%, EDTA, tetracycline) can be used.
Is there any benefit from the use of lasers or photodynamic therapy?
The use of lasers or photodynamic decontamination can be helpful in case of submerged healing of an augmentative treatment of peri-implantitis. However, there is limited evidence to support the use of lasers and photodynamic therapy (PDT) for implant surface decontamination.
Soft tissue management in combination with peri-implant disease
Goal: create soft tissue stability.
What is the rationale, and which are the indications to augment non-mobile keratinised mucosa in conjunction with surgical treatment of peri-implantitis?
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To optimise the possibility for performing an adequate level of oral hygiene in patients with an inadequate width (<2 mm) and thickness (<2 mm) of non-mobile keratinised mucosa.
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To facilitate flap management and wound stability.
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To help maintain peri-implant soft tissue health and stability.
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To improve aesthetics.
When should soft tissue augmentation be performed in conjunction with surgical therapy of peri-implantitis?
Limited data appear to indicate that soft tissue grafting in conjunction with a combined regenerative and resective surgical procedure may be effective in treating and controlling advanced peri-implantitis lesions by improving or maintaining the aesthetic outcomes. However, despite the lack of scientific evidence, the increase of non-mobile keratinised mucosa width and thickness before peri-implant surgical approaches appears to be reasonable.
What type of surgery and materials are recommended?
Various techniques, such as resective, ARF, regenerative or a combination of all, including the use of autogenous soft tissue grafts (FGG and CTG) or xeno-/allogenic materials have been shown to be successful for non-mobile keratinised mucosa augmentation. Autogenous material seems to be superior to xenogeneic or other substitute materials.
Clinicians should, however, carefully consider the removal/decrease of muscle activity, frenal pull, etc. before or during surgical treatment of peri-implantitis in order to facilitate the surgical approach and the clinical outcomes.
CONCLUSIONS
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Surgical non-regenerative modalities treating peri-implantitis can reduce the amount of inflammation in the short-term follow-up, but seem to have limited effectiveness in the long term.
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•
Implantoplasty in surgical non-regenerative treatment leads to a significant decrease in BOP and PD, and may result in improvement of clinical and radiographic parameters.
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•
Application of systemic antibiotics, chemical compounds or diode laser does not result in significant clinical or radiographic long-term improvements in a non-submerged approach.
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Surgical augmentative peri-implantitis therapy results in improved clinical and radiographic treatment outcomes.
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There is no evidence to support the superiority of a specific material, product or membrane in terms of long-term clinical treatment benefits of an augmentative approach.
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Due to the lack of comparative studies, no clinical recommendations can be given for the mode of healing (i.e. non-submerged vs. submerged) or for the adjunctive use of systemic antibiotics. However, when feasible, submerged post-operative wound closure is recommended in order to allow a protected physiological healing.
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All decontamination approaches with different tools and materials give similar results and fail to show the influence of a particular decontamination protocol on surgical therapy.
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Initial research as well as clinical experience show potential benefits of the use of lasers and new therapeutic approaches, such as PDT for surface decontamination in cases of submerged augmentative treatment of peri-implantitis, but without any definitive scientific evidence due to lack of comparative studies.
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The best outcomes to improve the width of KAM, bleeding and plaque scores, and to sustain the peri-implant marginal bone level is the use of an apically positioned flap combined with a free gingival graft.
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In patients with a thin phenotype or lack of an adequate width of KAM, soft tissue grafting may improve the clinical outcomes.
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Plaque control, post-operative maintenance and a non-smoking patient are still important factors for a successful surgical treatment of peri-implantitis.
Conflict of interest
The authors have no conflicts of interest to declare.
Funding
Funding for the FDI Peri-implant Diseases Project and Consensus Workshop was provided by the International Congress of Oral Implantologists.
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