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A pragmatic approach to manage
peri-implant biological complications

15.03.2024

Kristina Bertl1,2
Andreas Stavropoulos2,3,4,5

Introduction

Peri-implant biological complications, i.e., peri-implant mucositis or peri-implantitis, are frequent after implant installation. Prevalence rates of peri-implant mucositis and peri-implantitis present a wide range due to inconsistency in the used disease definitions. It is estimated that almost every second patient is affected by peri-implant mucositis and about every fourth to fifth by peri-implantitis of some extent (Derks & Tomasi 2015; Diaz et al. 2022; Salvi et al. 2019). Due to these high numbers and the constantly increasing number of implant installations (Klinge et al. 2018), diagnosis and management of peri-implant biological complications are integral parts of the daily clinical work.

Diagnosis

The World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions from 2017 established diagnostic criteria for peri-implant mucositis and peri-implantitis (Renvert et al. 2018). Peri-implant mucositis is defined as (1) presence of inflammation around the implant (i.e., redness, swelling, line or drop of bleeding within 30 seconds of probing), combined with (2) no additional bone loss after initial healing (figure 1).

Implant in position 26 with peri-implant mucositis (a–c). The probing depth value of 5 mm (b) remains consistent with the measurement taken a few weeks after placing the prosthetic reconstruction. There is bleeding on probing (c) but the radiograph indicates no additional bone loss beyond what is expected for marginal bone remodelling (d).
Figure 1. Implant in position 26 with peri-implant mucositis (a–c). The probing depth value of 5 mm (b) remains consistent with the measurement taken a few weeks after placing the prosthetic reconstruction. There is bleeding on probing (c) but the radiograph indicates no additional bone loss beyond what is expected for marginal bone remodelling (d).

Peri-implantitis is identified by (1) signs of inflammation similar to mucositis, (2) radiographic evidence of bone loss after initial healing and (3) an increase in probing depth compared to measurements taken shortly after placing the prosthetic reconstruction (figure 2). In the absence of previous radiographs, radiographic bone level of ≥ 3 mm along with bleeding on probing and probing depths ≥ 6 mm, indicates peri‐implantitis.

Full-arch restoration with peri-implantitis of varying degrees at some implants. The implant in position 21 is severely affected with probing depths up to 9 mm (a), bleeding on probing, and suppuration from the peri-implant sulcus and a vestibular fistula (b–c); the radiograph shows approximately 50 % bone loss for the implant with peri-implantitis in position 21, while the implant in position 23 shows limited bone loss, corresponding approximately to what can be expected after initial healing for this type of implants (d).
Figure 2. Full-arch restoration with peri-implantitis of varying degrees at some implants. The implant in position 21 is severely affected with probing depths up to 9 mm (a), bleeding on probing, and suppuration from the peri-implant sulcus and a vestibular fistula (b–c); the radiograph shows approximately 50 % bone loss for the implant with peri-implantitis in position 21, while the implant in position 23 shows limited bone loss, corresponding approximately to what can be expected after initial healing for this type of implants (d).

The expected bone loss after initial healing attributed to marginal bone remodelling, varies based on factors such as the implant system or type. For instance, 1–2 mm bone loss is generally considered “normal” for bone level implants with an external connection (figure 2d, implant in position 23).

A Mnemonic Approach to Radiographic Precision

To achieve consistent and comparable radiographs over time without overlapping implant-threads, a simple mnemonic rule can be followed: “right blur, raise beam & left blur, lower beam – RBRB/LBLB” (see figure 3 adapted from Schropp et al. 2012).

For optimal intraoral radiographs of dental implants, follow this mnemonic rule: If the right side of the implant appears blurry on the peri-apical x-ray, raise the beam (i.e., directed more towards the ceiling) (a); if the left side appears blurry, lower the beam (i.e., directed more towards the floor) (b). This rule applies regardless of implant position in the upper or lower jaw. Example: Blurry threads on implants at positions 14 and 16, mostly at their right side, (c) were corrected by raising the beam by about 15 degree, resulting in a clear image showing bone-to-implant contact (d).
Figure 3. For optimal intraoral radiographs of dental implants, follow this mnemonic rule: If the right side of the implant appears blurry on the peri-apical x-ray, raise the beam (i.e., directed more towards the ceiling) (a); if the left side appears blurry, lower the beam (i.e., directed more towards the floor) (b). This rule applies regardless of implant position in the upper or lower jaw. Example: Blurry threads on implants at positions 14 and 16, mostly at their right side, (c) were corrected by raising the beam by about 15 degree, resulting in a clear image showing bone-to-implant contact (d).

Oral hygiene aspects

Since the primary etiologic factor for peri-implant biological complications is the oral biofilm, two crucial aspects should always be considered as integral part of the treatment independent of a diagnosis of peri-implant mucositis or peri-implantitis: (1) the level of oral hygiene, and (2) the cleanability of the prosthetic restoration (figure 4).

Lower jaw full-arch restoration with significant plaque accumulation due to poor oral hygiene. Notice the large distance of the buccal aspect of the prosthesis to the implants on the right side (white arrows).
Figure 4. Lower jaw full-arch restoration with significant plaque accumulation due to poor oral hygiene. Notice the large distance of the buccal aspect of the prosthesis to the implants on the right side (white arrows).

Thus, both the patient's oral hygiene routines and the prosthetic restoration’s design and implant positioning should support effective cleaning. If required, adjustments to the existing restoration (figure 5) and specific instructions for tailored oral hygiene measures are essential (figure 6) (Hamilton et al. 2023; Jepsen et al. 2015).

Modification of an existing bridge restoration. If the restoration hinders sufficient oral hygiene measures (notice the extreme overhang on the buccal aspect of the molar) (a–b), one of the first treatment steps should be adjusting the prosthetic design to enable effective cleaning (c–d).
Figure 5. Modification of an existing bridge restoration. If the restoration hinders sufficient oral hygiene measures (notice the extreme overhang on the buccal aspect of the molar) (a–b), one of the first treatment steps should be adjusting the prosthetic design to enable effective cleaning (c–d).
Oral hygiene instructions. Patients should be instructed in detail in how to efficiently clean the implant restoration, considering variations in crown form and shape compared to natural dentition. A buccal overhang (a) might require a single tufted toothbrush in addition to the regular toothbrush (b).
Figure 6. Oral hygiene instructions. Patients should be instructed in detail in how to efficiently clean the implant restoration, considering variations in crown form and shape compared to natural dentition. A buccal overhang (a) might require a single tufted toothbrush in addition to the regular toothbrush (b).

Chemical agents (e.g., antiseptics, local antibiotics, acid treatment or anti-microbial photodynamic therapy) as adjuncts to mechanical plaque control are often used. However, due to a lack of sufficient data, there is no consensus on the potential benefit of additional chemical measures as adjunct to patient-administered plaque control measures (Gennai et al. 2023). Efficacy of adjunctive measures in peri-implant mucositis. A systematic review and meta-analysis. Journal of Clinical Periodontology, 1–27.) and a comprehensive disease resolution is typically challenging to attain without professional intervention (Salvi & Ramseier 2015).

Management of peri-implant mucositis

The concept of treating peri-implant mucositis is comparable to the treatment of gingivitis. The main approach is professional plaque control, aiming to mechanically disrupt the biofilm without altering the implant or abutment surface. Various methods using mechanical means are described in literature: curettes, (ultra)sonic scalers, air-polishing devices, laser application, etc. with or without the use of antimicrobial agents. Currently, no method has been consistently shown to be superior compared to others, while the use of systemic antibiotics is not recommended for the treatment of peri-implant mucositis (Dommisch et al. 2022; Gennai et al. 2023; Hallström et al. 2012; Herrera et al. 2023; Verket et al. 2023).

The choice of equipment depends on clinical circumstances, such as the distinction between calculus and soft plaque. Thus, in cases with calculus, titanium or plastic curettes, or specially designed tips for ultrasonic scalers should be used first, followed by the use of an air-polishing device (figure 7). In cases with only soft plaque accumulation, an air-polishing device alone can be sufficient. Air-polishing devices are operator and patient friendly and at least as efficient as standard instruments (Schwarz et al. 2015a).

Patient case with peri-implant mucositis, poor oral hygiene and calculus accumulation (a). In such case the combination of different equipment is advisable, i.e., specially designed tips for ultrasonic scalers are necessary to remove the calculus (b), and an air-polishing device helps in removing remaining soft biofilm (c–d).
Patient case with peri-implant mucositis, poor oral hygiene and calculus accumulation (a). In such case the combination of different equipment is advisable, i.e., specially designed tips for ultrasonic scalers are necessary to remove the calculus (b), and an air-polishing device helps in removing remaining soft biofilm (c–d).

To sum up, non-surgical treatment can be effective in addressing mucositis, serving as an essential step in the prevention of peri-implantitis. However, reports often indicate only modest and unpredictable improvements in crucial clinical and inflammatory outcomes, i.e., in reduction in bleeding on probing (BOP). In addition, there is a considerable risk of reinfection, and complete disease resolution is therefore not achievable in every single case of peri-implant mucositis (Herrera et al. 2023).

Management of peri-implantitis

Defect extent, implant position, and its strategic importance determine whether an implant can or should be treated. Similar to a non-treatable (hopeless) implant, a severely affected implant in a multiple-unit restoration may be irrelevant for treatment, as its loss does not compromise the prosthetic restoration. Consequently, it is advisable to consider explantation either upon diagnosis or during surgical intervention (figure 8).

Explantation of a severely affected implant using a piezo surgery device. The implant in position 43 was part of a 4-unit bridge supported by 3 implants. Because of significant bone loss and minor relevance in the support for the bridge, treating the implant was deemed impractical. Explantation was performed with a piezo surgery device and specially designed tips (a-c) ensuring a minimal amount of bone loss (d).
Figure 8. Explantation of a severely affected implant using a piezo surgery device. The implant in position 43 was part of a 4-unit bridge supported by 3 implants. Because of significant bone loss and minor relevance in the support for the bridge, treating the implant was deemed impractical. Explantation was performed with a piezo surgery device and specially designed tips (a-c) ensuring a minimal amount of bone loss (d).

Management of peri-implantitis at implants judged as treatable consists of a non-surgical phase, which is often followed by surgical intervention. For the non-surgical approach, similar measures as those applied for the treatment of peri-implant mucositis are used; based on laboratory experiments air-polishing devices with a subgingival nozzle appear to provide certain advantages in terms of biofilm removal, compared to hand- or ultrasonic instruments (Herrera et al. 2023; Moharrami et al. 2019; Ronay et al. 2017) (figure 9).

Patient case with peri-implantitis. The non-surgical treatment is performed by using the supragingival (a-b) and subgingival handpiece of an air-polishing device (c-d). Removing the supra-construction provides better access to the implant surface (d).
Figure 9. Patient case with peri-implantitis. The non-surgical treatment is performed by using the supragingival (a-b) and subgingival handpiece of an air-polishing device (c-d). Removing the supra-construction provides better access to the implant surface (d).

Yet, the non-surgical approach often has limitations in accessing the implant surface, leading to insufficient decontamination. This is indeed reflected in the clinic, where disease resolution after non-surgical treatment of peri-implantitis is rather unpredictable and recurrence is observed for most cases, i.e., disease resolution was reported to occur only in less than every second case (Ramanauskaite et al. 2021). Therefore, the outcome of non-surgical treatment needs to be evaluated after about 6 weeks, and in cases of moderate or advanced peri-implantitis, surgery should be expected.

The prosthetic restoration should be removed during both non-surgical and surgical treatment to improve access to the implant surface. The choice of surgical intervention (e.g., resective, reconstructive, or combined) depends on several factors: (1) defect morphology (e.g., horizontal, dehiscence, intra-osseous, or combined) (figure 10), (2) implant surface (i.e., turned or modified/”rough”), and (3) presence or absence of sufficient keratinised and attached mucosa.

Defect morphology is one of the parameters defining the type of surgical intervention. While circumferential intrabony defects (a) can be treated well with a reconstructive approach, primarily horizontal bone defects (b) require a more resective approach.
Figure 10. Defect morphology is one of the parameters defining the type of surgical intervention. While circumferential intrabony defects (a) can be treated well with a reconstructive approach, primarily horizontal bone defects (b) require a more resective approach.

A resective approach (i.e., gingivectomy and/or apically positioned flap, with/without bone re-contouring) should be chosen in cases with mainly horizontal bone loss or wide defects, where the potential for bone regeneration is limited (figure 11).

Patient treated with a resective approach (a). After flap elevation mainly horizontal bone loss is seen (b), addressed by bone re-contouring (c) and an apically displaced flap resulting in a stable post-operative result (d).
Figure 11. Patient treated with a resective approach (a). After flap elevation mainly horizontal bone loss is seen (b), addressed by bone re-contouring (c) and an apically displaced flap resulting in a stable post-operative result (d).

For implants with a modified surface and in regions where bone regeneration is unlikely, implantoplasty should be considered. This procedure involves removing implant threads and smoothing of the micro-structured implant surface with rotating instruments (figure 12). This approach facilitates comprehensive decontamination of the implant surface, and – most importantly – improves postoperative biofilm control (Bertl and Stavropoulus 2021; El Chaar et al. 2020; Geremias et al. 2017). Due to a lack of sufficient clinical evidence there is controversy about the role of implantoplasty (Herrera et al. 2023; Ramanauskaite et al. 2021), however the concerns about inducing inflammation by the inevitable deposition of titanium particles and the increased risk of implant fracture due to reduction of implant strength have not been substantiated (Stavropoulos et al. 2019).

For implants with a modified surface in areas where bone regeneration is limited, implantoplasty should be considered. In a case with a buccal dehiscence, the buccal aspect of the modified implant surface (a) underwent implantoplasty (b–d), with surrounding tissues covered to minimise contamination from titanium particles, using gauze and liquid rubber dam.
Figure 12. For implants with a modified surface in areas where bone regeneration is limited, implantoplasty should be considered. In a case with a buccal dehiscence, the buccal aspect of the modified implant surface (a) underwent implantoplasty (b–d), with surrounding tissues covered to minimise contamination from titanium particles, using gauze and liquid rubber dam.
An implant harbouring a primarily circumferential intrabony defect (a) should be treated with a reconstructive approach. For grafting, autologous bone was collected with a piezo surgery device (b-c) and the defect was covered with a collagen membrane (d).
Figure 13. An implant harbouring a primarily circumferential intrabony defect (a) should be treated with a reconstructive approach. For grafting, autologous bone was collected with a piezo surgery device (b-c) and the defect was covered with a collagen membrane (d).

A reconstructive approach is recommended for implants with modified surfaces and intra-osseous defects, where the potential for re-osseointegration is much higher (Monje et al. 2023; Renvert et al. 2009). This may encompass the utilisation of autogenous bone, bone substitutes, and/or membranes (figure 13) (Donos et al. 2023). Certainly, a reconstructive approach necessitates thorough decontamination of the implant surface. Both laboratory and preclinical studies indicate the impracticality of achieving complete biofilm removal from the implant surface (Subramani & Wismeijer 2012). Therefore, it is recommended to employ a combination of mechanical and chemical measures for effective decontamination, although no specific method can be considered as superior (Ramanauskaite et al. 2023; Wilensky et al. 2023). Air-polishing devices have demonstrated superior efficacy in biofilm removal based on several laboratory studies (Francis et al. 2022; Keim et al. 2019, Sahrmann et al., 2015). However, it is important to note that the intra-operative use of air-polishing is considered off-label.

Antibiotics as adjunct to surgical peri-implantitis treatment may be considered when a reconstructive approach, e.g., with bone substitute materials, is chosen (Heitz-Mayfield & Mombelli 2014), but otherwise standard use of antibiotics as adjunct measure to surgical peri-implantitis treatment is not recommended (Herrera et al. 2023).

Finally, it has been observed, that implants with less than 2 mm of keratinised mucosa exhibit an increased prevalence of peri-implantitis, and higher plaque accumulation and bleeding indices (Ramanauskaite et al. 2022). This highlights the importance of considering keratinised mucosa augmentation in peri-implantitis prevention and management (figure 14).

An implant lacking keratinised mucosa at the buccal aspect (a). To increase the width of the keratinised mucosa, a gingival graft was placed (b), enhancing oral hygiene effectiveness (c).
An implant lacking keratinised mucosa at the buccal aspect (a). To increase the width of the keratinised mucosa, a gingival graft was placed (b), enhancing oral hygiene effectiveness (c).

Conclusion

Treatment measures of peri-implant biological complications aim at infection and inflammation control, similarly to gingivitis and periodontitis. However, (1) although treatment of peri-implant mucositis is often successful, complete disease resolution may not be achievable in every single case, (2) bone loss progresses faster at implants compared with teeth, (3) non-surgical treatment is most often insufficient for peri-implantitis, (4) the type and extent of surgical intervention depends on defect morphology, implant surface, and the amount of peri-implant keratinised mucosa, and (5) the long-term outcome of peri-implantitis treatment is still largely unknown.

1) Department of Periodontology, Dental Clinic, Faculty of Medicine, Sigmund Freud University, Vienna, Austria
2) Department of Periodontology, Blekinge Hospital, Karlskrona, Sweden
3) Periodontology, Faculty of Odontology, Malmö University, Malmö, Sweden
4) Division of Conservative Dentistry and Periodontology, University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria
5) Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland

References

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