Prior to the placement of implants, a previous planning is necessary, which consists of a thorough evaluation and analysis in order to avoid the future appearance of the very common peri-implant diseases.
These diseases are described according to two clinical entities: peri-implant mucositis and peri-implantitis, both described as infectious entities.
- Peri-implant mucositis: characterized by the presence of inflammation in the peri-implant mucosa without signs of bone loss. It is usually reversible.
- Peri-implantitis: it is also accompanied by the loss of marginal supporting bone once the normal bone remodeling process is completed. Reversal in peri-implantitis is more complicated than in mucositis.
Prevalence of peri-implant diseases
The estimated prevalence for these two entities varies greatly depending on the study design and the definition of the disease. In 2008, it was established that peri-implant mucositis occurred in 80% of patients and 50% of implants, while peri-implantitis was identified in 28-56% of patients and 12-43% of implants.
A more recent systematic review (2015) reports a prevalence of mucositis and peri-implantitis of 43% and 22%, respectively.
Risk factors for peri-implant diseases.
At the 2008 European Workshop on Periodontology, numerous risk indicators were identified, classified according to greater or lesser evidence. Thus, poor oral hygiene, previous history of periodontitis, and smoking were considered of strong evidence; diabetes and alcohol consumption were considered of medium evidence; finally, genetic susceptibility and implant surface were considered of low evidence.
In addition, there is increasing evidence that residual cementum after placement of a restoration is a risk factor. An additional factor that has been named is occlusal overload.
Treatment of peri-implant diseases
The treatment protocol is complex and without consensus. Today there is no standard treatment, there are different therapeutic options, but there are some with more scientific evidence.
The proposed treatments for peri-implant diseases are based on the evidence of treatments for periodontal diseases.
Debridement (removal of biofilm) of the implant surface is the basic element in the treatment of mucositis and peri-implantitis. Two types of treatment are distinguished: non-surgical and surgical. With regard to peri-implant mucositis, non-surgical treatment was approved as causing reduction of inflammation (bleeding on probing), in combination with the adjuvant use of antimicrobial rinses. However, non-surgical treatment for peri-implantitis was unpredictable.
The main goal of surgical treatment in peri-implantitis is to gain access to the implant surface for debridement and decontamination to achieve resolution of the inflammatory lesion.
Surgical techniques and reconstructive procedures are usually more effective but limited to moderate and severe peri-implantitis.
Among the surgical treatments of peri-implantitis with greater scientific evidence are presented:
Resective surgery: aims to decontaminate the implant surface and expose the affected area of the implant to the oral cavity by detaching a flap, repositioning it in a more superior position for better hygiene self-control. It is often accompanied by an osteoplasty (smoothing of the surface of the implant that we leave exposed; we remove the coils in that area). This technique is very similar to the periodontal surgery performed in natural dentition, which allows the pocket depths to be reduced, facilitating the patient’s hygiene. This technique has clear disadvantages and is only recommended for regions without esthetic compromise.
Access surgery: it is a surgical way to decontaminate the implant surface, maintaining the soft tissues around the affected implant. It is recommended when bone loss is minimal. Access surgery can be combined with various methods such as curettes, abrasive air devices, ultrasonic devices and lasers to improve its effectiveness.
Regenerative surgery: mainly used to support tissues and prevent mucosal recessions. After decontamination of the implant surface, a graft should be placed around the implant, filling the peri-implant defect. The most commonly used grafts are either the patient’s own bone or bone substitutes. In addition, the use of connective tissue grafting in combination with bone grafting can have great esthetic advantages. The long-term goal of a regenerative process is the re-attachment of the peri-implant soft tissue and the enhancement of bone regeneration around the implant surface.
In summary, in order to avoid the appearance of future peri-implant diseases, a series of variables have been identified that dental specialists should take into account when carrying out surgical planning, since they would intervene in the increase of bacterial plaque around the implants and, as a consequence, in their bone loss.
It is essential that professionals identify these variables from the surgical planning stage in order to control them and, if necessary, modify the treatment protocol, as an important step in reducing the prevalence and risk of peri-implant diseases.