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Peri-Implantitis

Rescue of Implants Affected by Severe Peri-implantitis

In his lecture at the Geistlich + YOU online congress, Dr. Mario Roccuzzo offered his insights on treating cases of severe peri-implantitis using a protocol he has been successfully using over the last 20 years. In this interview, he answers some related questions.

Dr. Roccuzzo, you have been treating patients with soft‐ and hard‐tissue deficiencies for over 20 years.  What is the definition of peri-implantitis?

Dr. Roccuzzo: According to the consensus report of the World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions,1-2 “peri-implantitis is an infective pathologic condition affecting a previously installed dental implant, characterized by increased probing depth with concomitant bleeding and/or suppuration besides peri-implant bone loss”. Clinicians should use the scientific criteria for peri-implantitis diagnosis, as described in this consensus report.

How do you treat peri-implantitis?

Dr. Roccuzzo: There is no single treatment option that fits all peri-implantitis cases. In my experience, the treatment outcome depends on different factors, including the surface and morphology of the implant.3-4 We have recently published a clinical study with 10-year follow-up. There, the treatment in case of implants with sand-blasted and acid-etched surface was much more predictable compared to titanium plasma-sprayed surface implants.5 This makes me believe the time has arrived when the clinician should customize the treatment protocol according to implant characteristics!

What are your main considerations when opening the flap?

Dr. Roccuzzo: Even though access to the whole contaminated area is necessary, we should avoid opening big flaps wherever possible. This is necessary to prevent later tissue shrinkage. Recent findings in periodontology encourage clinicians to be more conservative in soft-tissue management: use minimally invasive approaches such as single flap opening and papilla preservation, to increase the possibilities of regeneration.

Which biomaterials do you use to regenerate the hard tissues around the implants?

Dr. Roccuzzo: When I use a regenerative approach, I use Geistlich Bio-Oss Collagen®. Also, when the keratinized mucosa around the implant collar is missing, I graft a dense connective tissue from the tuberosity. Having this soft-tissue seal around the collar of the implant is very important for the success of the treatment.

How do you remove contamination from the implant surface? Does this remove all the bacteria?

Dr. Roccuzzo: I use a titanium curette and titanium brushes, followed by EDTA 24% and chlorhexidine 1% gel each for 2 mins. I don’t know if this protocol removes all the bacteria, and I don’t even know if it is necessary to remove them all. There is no evidence that one decontamination method works better than the others.6 However, we know it is more difficult to treat peri-implantitis around implants with certain designs, e.g. implants with micro-grooves or aggressive thread.7 I really believe that in the future we should focus on the design of the implant surface and morphology.

Does your approach for bone regeneration change in case of different defect types?

Dr. Roccuzzo: Of course, I select the treatment protocol depending on the circumstances. But even when I use the regenerative protocol in challenging cases, I still get great results with Geistlich Bio-Oss® Collagen. I emphasize again that having dense and thick soft-tissue around the collar of implant is very important for predictability of outcome.

Does the connective tissue graft receive enough blood supply when it is positioned on top of Geistlich Bio-Oss® Collagen?

Dr. Roccuzzo: I cannot answer this question as a clinician. However, I have used Geistlich Bio-Oss® Collagen in the treatment of peri-implantitis in the last 15 years and had a very large number of difficult cases with excellent results. 

After how long can the implant be re-loaded again?

Dr. Roccuzzo: When you treat the peri-implantitis, the implant has not lost stability and osseointegration, and most of the time the crown is still in place. Thus, the implant can be loaded immediately. However, I ask patient not to brush or disturb the soft tissue until it is healed and stabilized.

Do you think that re-osseointegration of the implant is possible?

Dr. Roccuzzo: Experimental studies with animals show that re-osseointegration is possible.8 However, for me as a clinician, the goal is a long-term successful outcome for my patients and regeneration of stable and healthy soft-tissue around the implant after treatment. We have documented cases using the regenerative approach with 15-year follow-up. When this is achieved, neither the patient nor I worry what the process is called.

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Diagnosis and treatment of peri-implantitis and the outcome at 2.5-year follow-up. Case courtesy of Dr. Roccuzzo, Italy

What are the standards of care for patients after operations? Do you schedule regular follow-ups?

Dr. Roccuzzo: Of course. And please bear in mind there is a difference between a healthy patient and a periodontally compromised patient with a series of health issues, including peri-implantitis. For the later, the periodontal pockets and defect should be treated first, before treating the peri-implantitis.

The other important point is understanding the speed of spread of peri-implantitis compared to periodontitis. Peri-implantitis is usually a lot faster. This means, for patients with a history of periodontitis, a peri-implantitis defect might be quite large at the time of diagnosis, even if the patient is under a supportive periodontal and hygiene program.

Do you think there is any optimal implant design or surface characteristics to minimize the risk of peri-implantitis?

Dr. Roccuzzo: Probably yes. But we still have no evidence on which implant surface or design can significantly decrease the prevalence of peri-implantitis. In the future, we should not only focus on understanding which surfaces decrease the prevalence of peri-implantitis, but also which characteristics decelerate the progression of infection, and make the treatment more effective.

When do you choose not to treat the peri-implantitis, but take the implant out?

Dr. Roccuzzo: If patient has pain and the implant is not stable, the implant should be taken out. However, this is one of the hardest decisions, which should be made considering different factors. Is the implant properly placed? Is it properly restored? How long has it been in function? The pros and cons should be discussed with the patient to arrive at a common decision. It is very much like deciding whether the tooth should be extracted or restored.

What are the best practices for minimizing the prevalence of peri-implantitis in the future?

Dr. Roccuzzo: The key aspects are (1) correct patient selection and preparation, as implant therapy may be not the best option for every patient, (2) proper positioning of the implants, as poorly placed implants are less successful, and (3) soft-tissue integration, to facilitate effective maintenance care.

For so many years, our focus has been on osseointegration. Now we know soft-tissue integration and management are just as important, and much more difficult to achieve. Together with Anton Sculean, we have tackled this topic in a new book which will be published in the next months.

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