Peri-implantitis is an odontogenic infection accompanied by soft and bone tissue damage in the dental implant area and bone resorption. The clinic of peri-implantitis is characterized by pain in the implant area, hyperemia and swelling of the gum, formation of a gingival pocket, bleeding or suppuration, mobility of the structure. Peri-implantitis is diagnosed during a dental examination, taking into account complaints, clinical and radiological picture. Full–fledged treatment of peri-implantitis is carried out in stages: 1 (conservative) – removal of dental deposits and elimination of inflammation; 2 (surgical) – cleaning of the implant surface and bone grafting. In some cases, removal of the implant with subsequent reimplantation after the necessary treatment is indicated.
Peri-implantitis is an inflammation of the tissues around the osteointegrated implant, leading to a progressive loss of the supporting bone. According to clinical studies, when using various modern implantation systems, peri-implantitis develops in 12-43% of cases. Peri-implantitis is one of the most common causes of dental implant rejection. Mucositis should be distinguished from peri-implantitis – inflammation of the mucosal area adjacent to the implant without signs of bone loss.
Dental implantology is currently an actively developing area of modern dentistry. The number of patients with both removable and non-removable prostheses based on implants is steadily growing. In this regard, the issues of increasing the success of dental implantation and prevention of complications are of particular importance.
Etiological factors leading to the development of peri-implantitis may be associated with medical errors during the dental implantation procedure, the quality of the implantation system and prosthetic design, as well as poor oral hygiene. At the same time, in the immediate postoperative period, complications are usually caused by technical errors during the surgical stage of implantation and prosthetics, and in the long–term period – by the patient’s non-compliance with hygiene standards.
Medical errors are the cause of peri-implantitis relatively infrequently. Among them, there may be violations of the rules of asepsis and antiseptics; incorrect assessment of risk factors affecting the success of the procedure; incorrect selection and installation (positioning) of the intraosseous part of the implant, gum shaper, abutment; improperly manufactured orthopedic structures (crowns, prostheses), leading to overload and chronic periodontal injury, etc. The most typical factors causing peri-implantitis are the formation of a subgingival hematoma with its subsequent suppuration; the mismatch of the bone bed to the size of the implant, resulting in the mobility of the structure; destruction of bone tissue caused by excessive force of screwing the implant (more than 45 N/ m); inadequate suturing of the surgical wound, the presence of micro-gaps between the implant and the abutment.
As for the use of implantation systems of questionable quality for prosthetics, this cause of peri-implantitis is even rarer and can also be attributed to the sphere of medical responsibility. In this case, the complication may be due to the poor quality of the titanium alloy, the incomplete design of the implant, the use of fake implantation systems.
The most common cause of peri-implantitis is inadequate patient care for natural teeth, an implant and a prosthesis fixed on it, ignoring preventive examinations and professional oral hygiene. The design features of the implants predispose to the formation of plaque and tartar, which, in turn, causes inflammation of the surrounding tissues and peri-implantitis.
Smokers, patients with periodontal diseases (gingivitis, periodontitis), bruxism, immune disorders, diabetes mellitus are at risk for the development of peri-implantitis. The success of implant integration is influenced by the choice of implantation tactics (single-stage or classical), indications and contraindications to which should be taken into account when planning treatment.
The microbiological picture in peri–implantitis is similar to that in periodontitis: Prevotella intermedia is detected in 100%; Porphyromonas gingivalis – in 89%; Actinobacillus actinomycetemcomitans – in 85%; Bacteroides forsythus – 55%; Treponema denticola – in 41% of cases, etc.
In its development , peri-implantitis goes through 4 stages:
- I – characterized by a slight loss of bone tissue in the horizontal direction;
- II – characterized by a moderate decrease in bone height with the formation of a vertical defect in the area of the implant-bone connection;
- III – characterized by a moderate decrease in bone height with the formation of a vertical defect along the entire implant;
- IV – characterized by resorption of the bone of the alveolar process.
According to the clinical course, acute and sluggish (subclinical) peri-implantitis are distinguished; remission, abscess formation.
Mucositis, or periimplant inflammation, is clinically manifested by swelling and bleeding of the gums, hyperplasia of the periimplant cuff. Bone resorption does not occur in mucositis. In contrast to superficial inflammation, with peri-implantitis, there is a progressive loss of bone tissue. Patients complain of pain in the area of the installed implant, swelling, hyperemia and bleeding of the periimplant gum; formation of gingival pockets and fistulas, from which purulent contents can be released.
With the progression of inflammation and bone resorption, the mobility of the implant develops, which loses its functions. With grade III-IV peri-implantitis, there is a fairly high probability of implant rejection. Symptoms of periimplant inflammation can occur both in the near term after implantation, and in the long term (after many months and even years).
During an objective examination of patients with peri-implantitis, hyperemia and edema of soft tissues are determined. When probing the gums, bleeding is noted; when palpating the periimplant pocket, purulent exudate may be released from it. The implant is mobile; accumulation of soft plaque is detected on adjacent teeth and orthopedic structure. Evaluation of the condition of the periimplant gum is performed by stomatoscopy.
The crucial importance in the diagnosis of peri-implantitis and its degree belongs to X-ray studies: targeted dental x-ray, orthopantomography and 3-dimensional dental computed tomography, with the help of which bone resorption is detected. Laboratory studies – microscopic, bacteriological, morphological, PCR, biochemical, pH-metry of oral fluid – play an auxiliary role.
Full-fledged treatment of peri-implantitis is usually carried out in two stages and involves the elimination of gingival inflammation and surgical rehabilitation of the focus with directed bone regeneration. The conservative phase of peri-implantitis treatment includes professional oral hygiene, irrigation of peri-implant pockets with ozonated solution, laser therapy, oral baths and applications. Particular attention is paid to the removal of dental deposits from the crown and abutment. If necessary, the suprastructure is modified to eliminate biomechanical overload of the implant.
During the surgical stage of treatment of peri-implantitis, the incision and folding of the periodontal flap, revision of the bone pocket, removal of periimplant granulation tissues, cleaning of the implant surface with special curettes or the Prophy-Jet apparatus, detoxification of the implant surface with citric acid solution, thorough washing of the pocket is carried out. The operation ends with the introduction of osteoconductive material and a barrier membrane into the bone pocket and suturing of the surgical wound with the imposition of a protective periodontal bandage. In the postoperative period, antibiotics and antiseptic rinses are prescribed.
In case of recurrent or far-reaching peri-implantitis, the implant is removed with subsequent reimplantation.
Prognosis and prevention
Peri-implantitis can lead to rejection of the implant and subsequent long-term and expensive rehabilitation treatment. The use of high-quality implantation systems, high qualification of the dentist, modern methods of implantation planning (including with the use of 3D computer technologies) minimize the risks of peri-implantitis.
To prevent the development of peri-implantitis, patients should be under the supervision of an implantologist and a periodontist, follow the rules of dental care and orthopedic structures on dental implants, undergo occupational hygiene procedures within the recommended time frame. It is necessary to take a responsible approach to choosing a clinic and a specialist performing dental implantation.
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