1

CE
Credit

IMPLANT FUNDAMENTALS PART 3:

IMPLANT MAINTENANCE & REPLACEMENT
A Peer Reviewed Publication by Hu-Friedy
 SOLUTIONS OVERVIEW
IMPLANT FUNDAMENTALS

SCIENTIFIC REVIEWERS
Prof. Mauro Labanca Dr. Carlos Quinones

Private practice, Milan, Italy Associate Professor, Department

Consulting Professor of Anatomy, of Surgical Sciences, Division of
University of Brescia. Periodontics, University of
Puerto Rico School of Dental Medicine
Private practice, San Juan, Puerto Rico.

Dr. Lee Silverstein Dr. Jon Suzuki

Associate Clinical Professor of Professor, Department Chair, Program

Periodontics at the Georgia Health Director – Periodontology & Oral
Sciences University, Implantology Department
College of Dental Medicine Temple University Kornberg School of
Kennestone Periodontics Dentistry
Marietta, GA

Dr. István Urbán

Associate Professor, Department of

© 2019 by Hu-Friedy Mfg. Co., LLC
Periodontology,
University of Szeged, Hungary
Second Edition
Private practice, Budapest, Hungary
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording
or otherwise without written permission from the publisher. [655]

Hu-Friedy Mfg. Co., LLC. Approved PACE Program

Provider for FAGD/MAGD credit. Approval does not
imply acceptance by any regulatory authority, or AGD
endorsement. The current term of approval extends
from 6/1/2019 to 5/31/2022. Provider ID# 218966

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Patient Assessment Managing Peri-Implantitis
page 5 page 10

ABSTRACT
In this final part of Implant Fundamentals, participants will learn about the appropriate
care and maintenance that is necessary after an implant has been placed. This segment
reviews the different instrumentation that may be required to maintain healthy implants,
as well as the signs and symptoms of a failing implant that require replacement.

OBJECTIVES
At the conclusion of Part III, participants will be able to:
• Recognize the proper assessment, diagnoses, and treatment for dental implants
• Identify the key causes of implant failure
• Know how to maintain failing implants
• Identify when implant removal may be indicated

COMMERCIAL DISCLAIMER
This education program is made possible through the continued support of Hu-Friedy Mfg. Co., L.L.C. The author(s)
is a Hu-Friedy employee and/or consultant for different companies and organizations within the dental industry
and received payment and/or product as compensation for the time involved in the development this course.

This course was written for dentists and dental professionals from novice to skilled.

Educational Methods: This course is a self-instructional journal and web activity.

Requirements for Successful Completion: To obtain 1 CE credit for this educational activity you must review the
material, complete the course evaluation and obtain a score of at least 70% on the examination. Upon attaining
a passing score, you will receive an emailed copy of your certificate of completion for 1 CE or you may print it
immediately. This course is provided at no charge.

Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise. Participants
must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into
their practice. Only sound evidence-based dentistry should be used in patient therapy.
 CHAPTER 1:
IMPLANT MAINTENANCE

As dental implants have become the standard of care for restorations of totally or partially edentulous patients,
there is a resulting need for their ongoing maintenance (Kwan et al 1990). Dental implants, like other intraoral
structures, have the capacity to accumulate biofilm and calculus that must be effectively removed in order
to maintain proper oral health (Wilson et al 2014). Residual cement from the implant, for example, has been
identified as a causative factor for peri-implantitis and its management is critical to the long-term function of
the implant restoration. This chapter will explore the rationale and methods to evaluate the implant site and to
remove all deposits that can jeopardize the peri-implant tissues.

PHYSIOPATHOLOGY
Dental implants, as foreign bodies inserted into
PM
alveolar bone, may carry with them the complications
of a foreign body reaction. Dental implants are made Sulcus Sulcus
of biologically inert metal (usually titanium). When
inserted in the alveolar ridge, they are not supported 2.1mm JE JE
by connective tissues or junctional epithelium in the 1.8mm CT CT
same manner that natural teeth are (Figure 5.1).
Instead implants rely on osseointegration and sound
biomechanical principles to maintain stability over the
long term. Figure 5.1 Diagram of the mucosal barrier
that exists around a dental implant.
Because an implant prosthesis extends through the
oral mucosa and into the oral cavity, it is rapidly colonized
by bacteria (Charalampakis et al 2012; Koyanagi T et al
2013). Once the implant is placed, there is a “race to the
implant” between epithelialization and oral bacteria, and
the bacteria usually win (Zhao et al 2014). A physiological
biofilm forms that can act as a seal to keep bacteria out of
the recently drilled bone, but it can also act as a nidus of
infection since it is rich in oral bacteria (Sato et al 2014).
Clinicians must be aware of the delicate balance between a
healthy and a pathological biofilm. There are opportunities Figure 5.2 Clinical depiction of
for infection to occur as a result of either neglecting or peri-implant mucositis.
interrupting that barrier. Those infections are manifest as
peri-implant mucositis (Figure 5.2), a bacterial infection of
the soft tissues surrounding the implant, and peri-implantitis
(Figure 5.3), which implies crestal bone loss resulting from
this bacterial infection.

Figure 5.3 Elevation of surgical flap reveals

bone loss consistent with peri-implantitis.

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 PATIENT ASSESSMENT
Implant patients are encouraged to maintain a regular
maintenance program. Aspects of the patient’s history can
help predict the ultimate success or failure of the implant
(De la Rosa et al 2012). Patients that are known to lack good
oral hygiene are more prone to complications. Cigarette smoking
and bruxism are both strong risk factors for negative implant
treatment outcomes. Diabetes mellitus is also associated with a
higher incidence of mucositis and poor bone healing. Patients Figure 5.4 Probing serves a valuable role in
with active or previous periodontitis pose a higher risk of assessing hard tissue changes at the implant
site over time.
infection and failure, since a pathologic biofilm already exists in
the mouth. After the postsurgical healing period, symptoms of
pain, loosening, or bleeding may suggest peri-implantitis (Misch
2014). Upon examination, sensitivity to palpation or probing is
suggestive of peri-implant mucositis or an incomplete epithelial
seal around the implant.

Evaluation should include a thorough clinical and radiographic

examination that reviews the soft tissues, plaque/biofilm
monitoring, bone height, clinical probing, and implant mobility
(Alani and Bishop 2014) (Figures 5.4 to 5.6). Recommendations
point out that probing should be gentle using instruments Figure 5.5 Radiograph demonstrates an
that are less likely to abrade or roughen the surface of the implant with a healing abutment in place.

implant (Hasturk H et al 2013; Blasi et al 2014; Curylofo et al

2013). High-quality radiographs are required at intervals with
careful attention to alignment and positioning of the film in
order to accurately measure bone heights around mesial and
distal aspects of the implant. Note that conventional film-based
radiographs are mostly ineffective at evaluating lingual-buccal
bone loss.

Figure 5.6 Excess cement, visible in 6-year

follow-up x-ray, demonstrates loss of
alveolar bone over time.

Use Probing Depths as a Marker for

Bone Levels at the Implant Site
Effectively monitor for potential implant
complications chairside using periodontal probes
• Chart attachment levels at the implant
peri-mucosal area
• Use gentle yet thorough probing that does
not disrupt the biological seal

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DIAGNOSIS
On clinical examination, healthy tissues will be pink and epithelialized (i.e, firm and stippled, with knifelike edges),
with no suppuration or tenderness. In contrast, inflammatory lesions will show redness, swelling, bleeding upon
probing, suppuration, and tenderness — as well as lack of stippling (Figure 5.7). Peri-mucositis refers to an
inflammatory lesion residing in the mucosa. Peri-implantitis is an extension of that peri-mucositis, resulting in the loss
of the supporting bone around the fixture and will show a “saucerization” pattern around the implant radiographically
(English CE 1993; Sahm et al 2011). An unpleasant odor may be present as well. While routine radiographs will show
some bone loss in all patients, excessive bone loss predicts eventual implant failure (Misch 2014).

TREATMENT
Effective maintenance of a dental implant begins with conscientious
home care. Patients must be educated in instituting a recurring
and personalized oral care regimen to mitigate plaque/biofilm
accumulation (Corbella et al 2011; Costa et al 2012). Implant patients
are encouraged to brush twice daily with a soft brush and to perform
interdental cleaning with a soft brush (e.g., a proxy brush) or pulse
irrigation. An ADA-approved antimicrobial mouthwash or paste may
be helpful, especially in the immediate postoperative period or in
the presence of mucositis. The home self-care prescription is very
similar to the intensity of a home treatment protocol for periodontal
maintenance patients.
Figure 5.7 Side-by-side comparison of
The frequency of professional treatment for implant maintenance is healthy vs. unhealthy peri-implant tissues.
typically at 3–4 month intervals or up to one year depending on the
peri-implant health. Treatment includes mechanical and ultrasonic
debridement as necessary to disrupt the dental plaque biofilm from
the implant site (Kwan et al 1990; Jepsen et al 2015); air polishing
devices using low abrasive powders, like glycine or erythritol, help
overcome impediments, inhibiting plaque accumulation and removing
bacteria from implant surfaces (Graumann et al 2013; Sahm et al
2011). Air polishing devices using glycine powder, help to overcome
impediments in establishing bone-to-implant contact due to biofilms
and eliminate the risk of implant damage or negative effects to
surrounding tissues. Consequently, air polishing can be a valuable
component of ongoing implant maintenance conducted by the dental Figure 5.8 Plaque is removed with a
professional. gentle touch and gradually expanding
circumferential strokes.
Titanium is soft and easily scratched, which promotes plaque
formation on the roughened implant surface (Anastassiadis et
al 2015; Esposito et al 2014). Subgingival plaque removal can be
accomplished with low abrasive powder air polishing, rubber cup
polishing, hand or ultrasonic instruments. Hand scaling for calculus
removal is performed using oblique, circular, and parallel strokes
(Demiralp 2014) (Figures 5.8 and 5.9). If ultrasonic instrumentation
is used for calculus removal, it should be performed with a specialized
plastic tip to prevent iatrogenic damage to the implant. The choice
of instruments is based on access around the prosthetics, implant
location, peri-implant conditions and personal preference. When
Figure 5.9 Scaling is performed using
considering hand instruments, unfilled resin, titanium or carbon fiber oblique, circular, and parallel strokes.
materials are available. Polishing of the implant may be necessary
if its surface appears roughened.

6
 The goal of the periodic examination is to achieve a thorough assessment and cleaning without introducing
bacterial infection or damaging the implant or surrounding tissues (Grusovin et al 2010). Risk factors such as
bruxism, intake of sugary soft drinks, smoking, and neglect can be addressed at these periodic visits, and early
treatment intervention may help to save an ailing or failing implant.

PATIENT EDUCATION
Home care is critically important to the long-term
success of the implant. The patient can monitor for
signs of infection or failure and report to the dentist Perform Scaling Without Altering
early for treatment. Meticulous oral hygiene including Abutment Surfaces
brushing and flossing are encouraged, since pathogenic Keep implant components smooth and
bacteria from anywhere in the mouth will more prevent surface alterations that can
create an environment prone to plaque
aggressively attack these healing tissues. An ADA
entrapment and bacterial buildup
Council of Scientific Affairs accepted antimicrobial
• Reduce the potential for peri-implant
mouthrinse is often part of the recommended home
mucositis or peri-implantitis
care regimen as well. Follow-up evaluations are
recommended every three to six months, at least
initially, and can be spaced out (every 12 to 18 months,
with radiographs and occlusion checked as a part of this
recurring maintenance) with continued maturation of the implant (de Araujo Nobre et al 2014).
Again, patients should be counseled on smoking cessation,
treatment of bruxism, and control of comorbid conditions.

CONCLUSIONS
While implants and abutments are made of biologically inert materials and are manufactured with smooth,
polished surfaces, they are not protected from infection the way that teeth are. The thin epithelial seal around
the abutment provides little protection from invading bacteria. Because of these factors, preventive maintenance
is critical. Care must be taken to avoid problems through overly aggressive probing, scratching the implant, or
damaging the epithelial seal. Patient involvement is necessary to ensure long-term success of the implant.

7
 REFERENCES

Alani A, Bishop K. Peri-implantitis. Part 2: Prevention and maintenance of peri-implant health. Br Dent J 2014;217(6):289-297.

Anastassiadis PM, Hall C, Marino V, Bartold PM. Surface scratch assessment of titanium implant abutments and
cementum following instrumentation with metal curettes. Clin Oral Investig 2015;19(2):545-551.

Blasi A, Iorio‐Siciliano V, Pacenza C, Pomingi F, et al. Biofilm removal from implants supported restoration using
different instruments: A 6‐month comparative multicenter clinical study. Clin Oral Implants Res 2014.

Charalampakis G, Leonhardt A, Rabe P, Dahlen G. Clinical and microbiological characteristics of peri-implantitis cases:
A retrospective multicentre study. Clin Oral Implants Res 2012;23(9):1045-1054.

Corbella S, Del Fabbro M, Taschieri S, et al. Clinical evaluation of an implant maintenance protocol for the prevention of
peri-implant diseases in patients treated with immediately loaded full-arch rehabilitations. Int J Dent Hyg 011;9(3):216-222.

Costa FO, Takenaka‐Martinez S, Cota LOM, et al. Peri‐implant disease in subjects with and without preventive
maintenance: A 5‐year follow‐up. J Clin Periodontol 2012;39(2):173-181.

Curylofo FdA, Barbosa LA, Roselino AL, et al. Instrumentation of dental implants: A literature review. RSBO 2013;10(1):82-88.

de Araújo Nobre MA, Maló PS, Oliveira SH. Associations of clinical characteristics and interval between maintenance
visits with peri-implant pathology. J Oral Science 2014;56(2):143-150.

De la Rosa M, Rodríguez A, Sierra K, et al. Predictors of peri-implant bone loss during long-term maintenance of
patients treated with 10-mm implants and single crown restorations. Int J Oral Maxillofac implants 2012;28(3):798-802.

Demiralp B. Efficacy of different cleaning methods on the titanium surface in failed implants: In vitro study. 2014.

English CE. Biomechanical concerns with fixed partial dentures involving implants. Implant Dent 1993;2(4):221-242.

Esposito M, Ardebili Y, Worthington HV. Interventions for replacing missing teeth: Different types of dental implants.
Cochrane Database Syst Rev 2014;7:CD003815.

Fakhravar B, Khocht A, Jefferies SR, Suzuki JB. Probing and scaling instrumentation on implant abutment surfaces: An
in vitro study. Implant Dent 2012;21(4):311-316.

Graumann SJ, Sensat ML, Stoltenberg JL. Air polishing: A review of current literature. J Dent Hyg 2013;87(4):173-180.

Grusovin MG, Coulthard P, Worthington HV, et al. Interventions for replacing missing teeth: Maintaining and recovering
soft tissue health around dental implants. Cochrane Database Syst Rev 2010(8):CD003069.

Hasturk H, Nguyen DH, Sherzai H, Song X, et al. Comparison of the impact of scaler material composition on polished
titanium implant abutment surfaces. J Dent Hyg 2013;87(4):200-211.

Jepsen S, Berglundh T, Zitzmann NU. Group 3 of the 11th European Workshop on P. Primary prevention of
peri-implantitis: Managing peri-implant mucositis. J Clin Periodontol 2015;Jan 27.

Koyanagi T, Sakamoto M, Takeuchi Y, et al. Comprehensive microbiological findings in peri-implantitis and

periodontitis. J Clin Periodontol 2013;40(3):218-226.

Kwan JY, Zablotsky MH, Meffert RM. Implant maintenance using a modified ultrasonic instrument.
J Dent Hyg 1990;64(9):422,424-5,430.

Sahm N, Becker J, Santel T, Schwartz F. Non-surgical treatment of peri-implantitis using an air-abrasive device or
mechanical debridement and location application of chlorhexidine : A prospective, randomized, controlled clinical
study. J Clin Periodontol 2011; doi : 10.1111/j.1600-051X.2011.01762.x

Sato T, Kawamura Y, Yamaki K, et al. Oral microbiota in crevices around dental implants: Profiling of oral biofilm.
Interface Oral Health Science 2014: Springer; 2015:45-50.

Wilson Jr TG, Valderrama P, Rodrigues DB. Commentary: The case for routine maintenance of dental implants.
J Periodontol 2014;85(5):657-660.

Zhao B, van der Mei HC, Subbiahdoss G, et al. Soft tissue integration versus early biofilm formation on different dental
implant materials. Dental Materials. 2014;30(7):716-727.

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 CHAPTER 2:
IMPLANT REPLACEMENT

An implant restoration offers the dental professional and patient a predictable option for tooth replacement
(Misch 2014; Esposito et al 2005; Levin et al 2006; Levin et al 2005). High success rates have been reported for
dental implants (Misch 2014; Duyck and Naert 1998; Karoussis et al 2004; Romeo et al 2004), and numerous
investigators have attempted to define criteria for this success — most involving the absence of inflammation,
pain, or mobility at the implant site (Misch 2014). Nearly 30 years ago, Albrektsson established criteria that
remain important hallmarks of success with dental implants even today (1986):
• Single, unattached implants must be immobile when tested clinically;
• Peri-implant radiolucency must not be present;
• Marginal bone loss must be less than 0.2mm one year after placement;
• No signs or symptoms of pain, paresthesia, or violation of the mandibular canal; and
• Success rates of 85% and 80% at five and ten years, respectively.
While implant dentistry has become the standard of care for replacing missing teeth, failures do occur and
can require timely implant removal (Misch 2014; Duyck and Naert 1998; Esposito et al 2005; Karoussis et al
2004). In such instances, the members of the interdisciplinary team must take appropriate steps to manage the
compromised site, as implant removal can jeopardize efforts to achieve function and aesthetics as well as result
in additional expense and procedures for the patient.

It is important to recognize that unhealthy dental implants have been categorized as “ailing” or “failing.” Ailing
implants are those with signs of bone loss and pocketing. This pocketing is historically stable upon assessment
at maintenance appointments and does not progress. Failing implants, by contrast, refer to those showing signs
of alveolar bone loss with unstable pocketing. Failing implants are
often associated with continuing changes in bone architecture,
purulence, and bleeding upon probing (Misch et al 2008;
Jovanovic 1999).

CAUSES OF IMPLANT FAILURE

A number of patient-related factors influence implant
survival, including his/her overall health, smoking habits, and
compliance with oral hygiene instruction. Uncontrolled diabetes, Figure 6.1 Radiograph of bacterial
chemotherapy, and the patient’s failure to wear a night guard also plaque-induced destruction of the
peri-implant tissues.
play a role. Each should be emphasized with the patient prior to
and throughout implant treatment in order to predispose the case
for success (Levin and Schwartz-Arad 2005).

Implant failure is often multifactorial, and the interdisciplinary

team has considerations to manage throughout treatment as
well. Overheating, contamination and/or trauma to the implant
site during surgery, insufficient bone quality or quantity, and lack
of primary stability have each been attributed to failures in the
early phase of dental implant therapy (Levin 2008). Following
Figure 6.2 Histological view of peri-implant
implant placement, causes of failure have been attributed to peri-
tissue destruction, attributed to occlusal
implantitis (Figure 6.1), occlusal trauma (Figure 6.2), trauma, that requires surgical intervention
and occlusal control.

9
the type of implant surface, and overloading of the implant (Misch 2014; Levin 2008). Marginal bone loss is
also a factor jeopardizing the long-term survival of a dental implant, and viewing this with radiographs can
provide the interdisciplinary team with a convenient means of assessing implant health and predicting its future
success. Combined with occlusal analysis, prosthetic evaluation, surgical intervention, and hygiene maintenance
(which should include ongoing assessment of probing depth and attachment levels), radiographic evaluation
provides valuable information on whether or not the implant is predisposed for failure and why.

MANAGING IMPLANT FAILURES

Failure to Osseointegrate
When an implant has failed to osseointegrate, it is
possible for the interdisciplinary team to remove
the implant and, following removal of all granulation
tissue, attempt placement of a fixture with a larger
diameter implant (Evian and Cutler 1995). As with the
original implant placement, this objective must be
carefully balanced by the individual factors present.
Patients lacking sufficient bone, poor aesthetic
situations, and the presence of infection can all be
contraindications to immediate re-implantation and Figure 6.3 Implant failure that requires
may require a delayed surgical approach. surgical intervention.

It is also possible to perform guided bone

regeneration at the site and re-attempt implant
placement (Figures 6.3 through 6.5) (Misch
2014; Chee and Jivraj 1998). Removal of a non-
cylindrical implant (e.g., a blade implant) can cause
hard and soft tissue loss as well as the need for
subsequent reconstructive surgeries to effectuate
repair, and some authors have discouraged
the use of non-cylindrical designs in order to
prevent this occurrence (Chee and Jivraj 1998).
When replacement is attempted at a site where Figure 6.4 Guided tissue regeneration performed
at site of implant failure.
osseointegration has failed previously, discussion
with the patient is imperative in order to share the
predictability of such treatment and to obtain
his/her informed consent to proceed with the
second attempt.

Peri-Implantitis
When bone loss occurs on an integrated implant,
the treatment team faces a greater challenge.
This situation, often attributed to peri-implantitis,
usually occurs only after placement of the definitive
restoration. Peri-implantitis is an inflammatory Figure 6.5 Clinical outcome of peri-implantitis addressed
condition around dental implants and is often via guided bone regeneration, i.e., surgical approach.
associated with the loss of surrounding bone (i.e.,
greater than 0.2mm annually) after the anticipated
physiologic remodeling (Hsu and Kim 2014). Appropriate management of this condition may require referral
to a periodontist, as the long-term objective is to halt the progression of the disease (e.g., purulence,
bleeding, swelling) and maintain the implant site.

10
 It is important to manage the bacterial infection and reduce inflammation. Ultrasonic debridement is
clinically effective in controlling the progression of peri-implantitis, especially when combined with an adjunct
chemical agent such as a disinfectant irrigant or antibiotic therapy. In addition, air polishing devices have
been shown to be useful in the treatment of peri-implant disease when guided in circular motions (coronal
to apical) parallel to the implant surface. The patient’s home care should be examined to ensure proper
oral hygiene regimen is in place, and he or she should be reappointed on a more frequent basis to permit
evaluation of the site.

There is no clear evidence in the literature that nonsurgical therapy can effectively stop the progress of peri-
implant bone loss, though the applications of air polishing and laser therapy have shown the ability to reverse
peri-mucositis (Lang & Berglundh 2011; Renvert et al 2008). Removal of the implants or resection of tissue to
treat pocket depth are seemingly the only predictable ways of managing peri-implant bone loss. This can lead to
severe disfigurement and compromised aesthetics — particularly in anterior regions.

Surgical intervention may be appropriate if, at re-evaluation, the patient has not responded to nonsurgical
therapy and active infection is still present with visible bone loss. It is advisable to:

1. 
Reflect a flap and assess for potential cement entrapment subgingivally, as this etiology is responsible for a
growing number of implant failures (Hsu and Kim 2014).

2. 
Degranulate the defect using surgical curettes. If the implant is coated with hydroxyapatite (HA) that is
resorbing or demonstrates a change in color, remove the HA coating (Misch 2014).

3. 
Detoxify the implant surface with power scaling, air polishing units, the use of titanium surgical brushes, or
through the application of chemotherapeutic agents (e.g., supersaturated citric acid or tetracycline applied
with cotton pellets or a brush) (Misch 2014).

4. 
Perform flap management with resective or regenerative approaches, as guided by the extent of bone
destruction present, and protect the graft with a membrane as needed.

5. 
Leave the repaired site out of function and protected for 10 to 12 weeks (Misch 2014).

11
 If the etiology of failure is biomechanical in nature, the interdisciplinary team should focus on the fit of the
prosthesis and its occlusal load. When no active infection is present and the implant appears intact without
progressive bone resorption, the bone loss may be attributed to traumatic occlusion, overloading, or off-axis
loading. The following corrective actions should be implemented:

1. 
Correct the prosthetic design and improve implant number and position and perform occlusal equilibration.

2. 
Reflect the tissue and degranulate the defect using surgical curettes.

3. 
Detoxify the dental implant with air abrasive units or through the application of supersaturated citric acid or
etching gel applied with cotton pellets or a brush. Thirty seconds per surface is sufficient.

4. C
 ombine two 500 mg tablets of Tetracycline powder with sterile saline into a paste, and pack around the
peri-implantitis implant for 60 seconds; wash off.

5. 
Flush and irrigate with sterile water or sterile saline to stop the demineralization process of the acid.

6. 
Continue with grafting, guided bone regeneration materials, and procedures as previously noted above.

Note the only difference is that removal of HA

is not necessary, as the coating is relatively
TABLE 6.1
uncontaminated and still capable of biological
CRITERIA FOR IMPLANT REMOVAL
healing (Misch 2014).
Pain upon palpation, percussion, or function
In his 2015 text Dental Implant Prosthetics, Horizontal mobility over 0.5mm
Misch outlined specific criteria that constituted Vertical mobility of any kind
clinical failure and would require implant removal Progressive bone loss that cannot be controlled
(Table 6.1). According to Misch, these implant Uncontrolled exudate
sites, as well as those where implants were More than 50% bone loss around the implant
surgically removed or exfoliated, can be grafted
Generalized radiolucency
with autogenous or synthetic graft materials in
order to return the bone quality and quantity to
favorable conditions that permit a new attempt
at implant placement.

CONCLUSIONS
The primary criteria for assessing implant success are the absence of inflammation, pain, and mobility, each a
signifier of the fixture’s potential for failure. Clinical evaluation via probing and radiographic examination provide
the interdisciplinary team with useful information regarding the long-term prognosis of implant treatment,
and surgical intervention may be necessary in patients with failing implants in order to restore sufficient bone
quality for re-implantation.

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 REFERENCES

Albrektsson T, Zarb GA, Worthington P, et al. The long-term efficacy of currently used dental implants: A review
and proposed criteria for success. In J Oral Maxillofac Implants 1986;1:1-25.

Chee W, Jivraj S. Failures in implant dentistry. Brit Dent J 2007;202:123-129.

Duyck J, Naert I. Failure of oral implants: Aetiology, symptoms and influencing factors. Clin Oral Invest.
1998;2:102-14. Levin L. Dealing with dental implant failures. J Appl Oral Sci 2008;16(3):171-175.

Esposito AC, Sheiham A. The relationship between satisfaction with mouth and number and position of teeth.
J Oral Rehabil 1998;25:649-661.

Esposito M, Grusovin MG, Coulthard P, et al. A 5-year follow-up comparative analysis of the efficacy of various
osseointegrated dental implant systems: A systematic review of randomized controlled clinical trials. Int J Oral
Maxillofac Implants 2005;20:557-568.

Evian CI, Cutler SA. Direct replacement of failed CP titanium implants with larger-diameter, HA-coated Ti-6Al-4V
implants: Report of five cases. Int J Oral Maxillofac Implants 1995;10:736-743.

Hsu A, Kim JWM. How to manage a patient with peri-implantitis. J Canad Dental Assoc 2014;79:e24.

Jovanovic SA. Peri-implant tissue response to pathological insults. Advances Dental Res 1999;13:82-86.

Karoussis IK, Brägger U, Salvi GE, et al. Effect of implant design on survival and success rates of titanium oral
implants: A 10-year prospective cohort study of the ITI Dental Implant System. Clin Oral Implants
Res 2004;15:8-17.

Lang NP, Berglundh T. Peri-implant diseases—Consensus report of the 7th European Workshop on Periodontology
2011;38(Suppl):178-181.

Levin L, Laviv A, Schwartz-Arad D. Long-term success of implants replacing a single molar. J Periodontol
2006;77(9):1528-1532.

Levin L, Pathael S, Dolev E, Schwartz-Arad D. Aesthetic versus surgical success of single dental implants: 1- to
9-year follow-up. Pract Proced Aesthet Dent. 2005;17:533-538.

Levin L, Sadet P, Grossmann Y. A retrospective evaluation of 1387 single-tooth implants: A six-year follow up.
J Periodontol 2006;77:2080-2083.

Levin L, Schwartz-Arad D. The effect of cigarette smoking on dental implants and related surgery. Implant Dent
2005;14(4):357-61.

Misch CE. Dental Implant Prosthetics. 2nd ed. Elsevier, St. Louis, MO. 2015.

Misch CE, Perel ML, Wang HL, et al. Implant success, survival, and failure. The International Congress of Oral
Implantologists Pisa Consensus Conference, Implant Dent 2008;17:5-15.

Renvert S, Roos Jansaker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis:
A literature review. J Clin Periodontology 2008;35:305-315.

Romeo E, Lops D, Margutti E, et al. Long-term survival and success of oral implants in the treatment of full and
partial arches: A 7-year prospective study with the ITI dental implant system. Int J Oral Maxillofac Implants
2004;19:247-259.

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 REFERENCES

Saadoun AP. Immediate implant placement and temporization in extraction and healing sites. Compend Contin
Educ Dent 2002;23:309–326.

Saadoun AP, Le Gall MG, Touati, B. Current trends in implantology: Part II—Treatment planning, aesthetic
considerations, and tissue regeneration. Pract Proced Aesthet Dent 2004;16(10):707-714.

Salinas T. Soft tissue punch technique for aesthetic implant dentistry. Pract Periodont Aesthet Dent
1998;10(4):434.

Schropp L, Isidor F, Kostopoulos L, et al. Patient experience of and satisfaction with, delayed-immediate vs.
delayed single-tooth implant placement. Clin Oral Res 2004;15:498–503.

Schwartz-Arad D, Laviv A, Levin L. Survival of immediately provisionalized dental implants placed immediately into
fresh extraction sockets. J Periodontol 2007;78:219–33.

Singh P, Cranin N. Hard tissue surgery and bone grafting. In: Atlas of Oral Implantology, 3rd. Ed. Mosby, 2010.

Smith GD, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567-572.

Suzuki, and Misch, Chapter 42, Misch Contemporary Implant Dentistry, 2012. Elsevior Mosby.

Suzuki, and Misch, Chapter 32, Misch Implant Prothetics. 2014. Elsevior Mosby.

Vlahovic Z, Markovic A, Golubovic M, et al. Histopathological comparative analysis of peri-implant soft tissue
response after dental implant placement with flap and flapless surgical technique. Experimental study in pigs.
Clin Oral Impl Res 00, 2014, 1–6 doi:

Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen
consecutive case reports. Pract Periodontics Aesthet Dent 1998;10:1107–1014.
Images presented with permission of the copyright holder and courtesy of Dr. Joseph Kan, Dr. Perry Klokkevold, Dr. Michael Klein, Dr. John Kois,
and Dr. Adilson Torreao.

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