Step 1 – Assessing the situation
The implant-supported prosthesis should be evaluated to determine if there are any causative factors such as screw-loosening, excess luting cement, poor abutment fit or poor prosthesis contour. The prosthesis should also fit well and provide access for easy cleaning. Corrections should be made where necessary (this may involve removal of the prosthesis). Risk factors, including poor oral hygiene, smoking, diabetes or the presence of deep periodontal pockets, should also be addressed.1
Step 2 – Non-surgical debridement
Non-surgical debridement using appropriate instruments, such as titanium curettes, air-powder abrasive devices, ultrasonic devices, photodynamic therapy, or Er:YAG laser, should precede surgical intervention. Systemic antibiotics, local antimicrobials and/or the use of topical antiseptics (e.g., chlorhexidine) may be concomitantly prescribed. Individual oral hygiene instruction should be provided to ensure good plaque control.
Step 3 – Re-assessment
A re-evaluation should be made approximately four weeks after nonsurgical debridement to determine if there has been a resolution of peri-implantitis. Some cases of peri-implantitis will resolve following nonsurgical management, in which case patients can continue with regular home and professional maintenance care.
Step 4 – Surgical intervention
If the peri-implantitis has not resolved at re-evaluation, a surgical approach is recommended. Surgical intervention is frequently required when the peri-implantitis lesion is severe with advanced bone loss and deep peri-implant pockets. The presence of retained excess luting cement located submucosally usually requires a surgical access approach for cement removal. Surgical management involves elevating a full mucoperiostal flap and removing the inflammatory tissue to allow thorough decontamination of the implant surface. Currently there is no single decontamination method that has proved to be superior.
Access flap approach: In the access flap approach, no attempt is made to regenerate the bone. Soft-tissue recession is frequently observed as a part of the healing process.2
Resective approach: The bone peaks around the implant are removed or reshaped to allow the flap margins to be positioned apically. Implantoplasty, i.e., modification of the implant surface using a carbide or diamond bur, has also been described in conjunction with this treatment modality.
The regenerative approach involves filling the intrabony component of the defect with a bone graft or bone substitute material followed by coverage with a barrier membrane. Several studies have shown that regenerative approaches can provide successful long-term treatment outcomes in the majority of patients.3-6
Step 5 – Post-surgical care
During the immediate post-operative healing phase, daily rinsing with chlorhexidine is recommended to provide adequate biofilm control. Peri-operative systemic antimicrobials are commonly prescribed to suppress the microbial load, particularly with specific periodontal and peri-implant pathogens.
Step 6 – Maintenance care
Regular monitoring, oral hygiene reinforcement and professional biofilm removal is required to avoid reinfection or the recurrence of peri-implantitis. The frequency of maintenance depends on the risk assessment for each patient. Relevant factors include smoking habits, periodontal status, diabetes and oral hygiene.7