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peri-implantitis

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adrian manaloto

on 19 November 2016

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Transcript of peri-implantitis

Peri-implantitis treatment interventions

Peri-implant pathologies comprise all inflammatory
lesions
appearing
around functioning dental implants
Ericsson et al., 1995
Two principal phenomena
1. Mucositis
2. Peri-implantitis
appearance of an inflammation
limited to the peri-implant mucosa and reversible
in case of appropriate treatment.
Jovanovic et al., 1993
characterized by a
loss of supporting bone,
both clinically and radiographically proven associated with an inflammatory reaction of the surrounding soft tissues.
Mombelli et al., 1998
Usual characteristics
1. Saucer shaped (well demarcarted)
2. Bleeding after gentle probing
3. Possible suppuration
4. Swelling and redness
5. No pain (most cases)
Bjorn et al., 2005
Buccal and lingual osseous lesions are not detectable by this tool..
Triggering factors for peri-implantitis
1. Lesions of peri-implant attachment
2. Presence of aggressive bacterial strains
3. Excessive mechanical stress
4. Corrosion

Peri-implantitis soft tissues act as a protection barrier for bone tissues sustaining the implant
Lindhe et al., 2000

This is the reason why the concept of platform switching is made, creating a distance between the prosthetic part and the osseointegrated interface of the implant.
Micro-organisms most frequently associated with implant failures (
rods and mobile Gram-negative anaerobes
)
1. Prevotella intermedia
2. Porphyromonas gingivalis
3. Actinobacillus actinomycetemcomitans
4. Bacteroides forsythus
5. Treponema denticola
6. Prevotella nigrescens
7. Peptostreptococcus micros
8. Fusobacterium nucleatum
Excessive biomechanical stress (promotes initial rupture of osseointegration)
1. Excessive mechanical axial or lateral constraints
2. Excessive occlusion of the implant prosthesis
3. Presence of natural antagonistic teeth
4. Presence of parafunctions ( bruxism...)
Biomechanical parameters to be taken account before treatment
1. Homogenous distribution of sufficient number of implants
2. Reasonable use of cantilever prostheses and removable prosthesis stabilization bars
3. Real passivity of the metal reinforcements
4. Even restriction of the clinical heights of crown in accordance to implants length
5. *Quality of bone
Corrosion (secondary factor) if base metal alloy is used in direct connection to titanium implant

*macrophage accumulations can contribute to bone tissue destruction without bacterial pathogenic flora intervention.
Figure 4 During peri-implantitis, a typical circumferential bone resorption (U crater) appears around implants (A), and the bottom of this crater is often on the line of implant break and correspond to the extremity of abutment screw (the weakest part of the complex implant–abutment–crown) (B). Signs of corrosion are easily observed on the soft tissue surrounding a broken implant (C). A burr is often needed to remove the nonmobile apical part of a broken fixture (D,E) still looking osseointegrated with hard tissue attached to the implant surface (F). Scanning electron microscope examination shows a bone-like structure (G), while light microscopy reveals in fact a dense fibrous tissue (H,I).
Chemical and physical processes in order to
decontaminate the implant surface while reestablishing
a surface compatible with osseointegration.

1. Vaporization of bacterial and inflammatory debris by means of CO2 laser
2. Citric acid application to detach burnt remnants from titanium (rinse generously)
3. H2O2 application (as an oxygen source), which will be evaporated in situ with CO2 laser beam
Figure 6 Schematic view (up) and related SEM pictures (down) of a potential efficient surface treatment after peri-implantitis.
In conclusion,
There is still no reliable evidence available for the most effective treatment protocol for peri-implantitis. Patient recall longer than 1 year may be suggested to observe if the re-occurrence of peri-implantitis may happen. Larger RCTs with more than 1 year follow-up should be implemented.
Thank you for your attention
In addition...
Non-surgical Approach
Peri-implant mucositis non-surgical debridement and personal oral hygiene
without adjunctive use of chlorhexidine gel
were effective means to treat peri-implant mucositis
Heitz-Mayfield et al., 2011

Air-abrasive device may be more efficient
in disrupting the peri-implant biofilm and reducing bacterial load that the use of carbon curettes with chlorhexidine antiseptic therapy
Sahm et al., 2011
The
use of erbium-doped:yttrium, aluminum and garnet (Er-YAG laser and an air-abrasive device (Perio-Flow)
, decreased probing pocket depth, bleeding on probing, and frequency of suppuration.
Renvert et al., 2011
Surgical approach
(Regenerative)
Flap elevation, removal of granulation tissue,
"implantoplasty"
surface decontamination by either plastic curettes followed by abundant saline irrigation or by Er:YAG laser, and bone graft
decreased BOP, improved bone fill, and clinical attachment level
Shwarz et al., 2011

Use of 24% EDTA and 1% chlorhexidine
followed by the use of combined bovine bone mineral and collagen xenograft
improved

PPD, BOP, plaque, suppuration and radiographic bone level after 1 year.
Rocuzzo et al., 2011
Surgical approach
(Resective)
Systemic antibiotics (
clindamycin
) a week starting on surgery day, plaque control before and after surgery,
"Pocket elimination surgery"
(involving bone recontouring to eliminate the angular bone defect around affected implant) were efficient in treating peri-implantitis at 2 years follow-up.
Serino and Turri, 2011
first European Workshop on Periodontology (1993)
Definition
Peri-implant disease
: inflammatory process in the tissue surrounding an implant
Peri-implant
mucositis
: reversible inflammatory process in the
soft tissue
surrounding a functional implants
Peri-implantitis
: an inflammatory process additionally characterized by
loss of peri-implant bone
Adrian Carlos F. Manaloto, DMD, MSc
Professor, Dept. of Prosthodontics, UE Grad. School
Peri-implant
mucositis
: approximately
50%
of the implants.
Peri-implantitis
: between
12% and 43%
of implant sites.

the most common lesions that occur, i.e. peri-implant mucositis and peri-implantitis are caused by
bacteria
.
Risk indicators
A number of risk indicators were identified
including
Poor oral hygiene
A history of periodontitis
Diabetes
Smoking

long-term corticoid treatments
radiotherapy
chemotherapy

(Consensus Report of the Sixth European Workshop on Periodontology)
Treatment
Mechanical tx
Non-surgical
Surgical
-resective therapy
-regenerative therapy
Antimicrobial Tx.
Systemic
Local
Indication :
Peri-implant mucositis
Oral hygiene instruction
Plaque control
Antiseptics
Antimicrobial treatment
Resective therapy
Moderate to severe horizontal bone loss
1,2 wall defect
Implant position in unethetic area
Gingivectomy, Flap operation
Implantoplasty
Regenerative therapy
Moderate to severe circumferential intrabony defect
2.3wall defect Detoxification of implant surface
Bone graft, GBR
Mechanical device

- Air powder abrasive unit (Prophy Jet)
- Cotton pellet
- Laser
Implant surface detoxification
Chemical control
- Chlorhexidine gluconate
- Tetracycline HCL
- Citric acid
- Hydrogen peroxide
Reosseointegration
*previously contaminated but cleaned and conditioned titanium surface was
difficult/impossible
.
Persson et al. 1999

may occur at failing implant site treated according to the
principles of GBR
.
Jovanovic et al. 1993
Adjunctive systemic & local antimicrobial therapy
Resolve inflammation
Doesn't promote re-osseointegration
C
umulative
I
nterceptive
S
upportive
T
herapy(
CIST
) Protocol

Lang et al JOMI 2004
Oral hygiene re-instruction
Mechanical debridement with non metalic curettes
Polishing with nonabrasive polishing powder
Mouthrince with 0.1-0.2% CHX for 30sec using 10ml
local CHX gel (0.2%)
Local irrigation with CHX (0.2%) 2 times a day for 3-4weeks
Systemic
- Ornidazole(1000mg X 1) or
MDZ(250mg X 3) for 10days
- AMX(375mg X 3) + MDZ(250mg X 3) for
3days
Local
- controlled release device for 10days
- TC fibers, minocycline microsphere
Systemic antibiotics
Implant surface decontamination
Regenerative technique
- Barrier membrane alone
- Barrier membrane + auto bone, bone substitute
Resective surgery
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