PERI-IMPLANTITIS

SRIJANA HEKA

BDS IV YEAR

ROLL NO: 17
• CONTENTS:
 Introduction
 Etiology and risk factors
 Classification
 Clinical features
 Histopathology
 Diagnosis
 Prevention and criteria for successful
implants
 Management
 Conclusion
 References
 INTRODUCTION
 Peri-implant diseases: inflammatory
processes in tissues surrounding
implant –Albrektsson and Isidor,1994

 Peri-implant mucositis: reversible

inflammatory process in soft tissues
surrounding functioning implant.
 Peri-implantitis :
 Is defined as an inflammatory process
affecting the tissue around an
osseointegrated implant in function
,resulting in loss of supporting bone.
 Ridge mucosa :

• Edentulous, hard tissue portion of alveolar

process is covered by mucosa that is about
2-4mm.

• Lined by keratinized epithelium.

• Rich in fibroblasts and collagens.

• Few inflammatory cells scattered adjacent

to the basement membrane.
Peri-implant mucosa :
Transmucosal
After implant
passage
installation
formed

Mucosa adapts
and peri-implant
mucosa established

Mucosa with similar Lined by

features to gingiva keratinized
around teeth
oral epithelium
Implant mucosa v/s physiological periodontium

 Peri implant mucosa  Physiological periodontium

• Direct bone to implant • Anchoring system of
contact. cementum alveolar bone
and desmodontic fibers.

• Subepithelially more • Subepithelially more

collagen less fibroblasts fibroblasts and vessels.
and vessels.
• Dentogingival,dentoperio
• Parallel collagen fibers in steal ,transseptal and
relation to implant circular fibers
surface. orientation.
Implant v/s physiologic periodontium
Etiology:
 Bacterial infection

 Biomechanical overload

 Other co-factors like

• Relationship between surface roughness
of implants and bacterial colonization.
 Other risk factors :
• Poor oral hygiene

• Smoking

• History of periodontitis

• Compromised host response and

systemic diseases like diabetes
mellitus ,cvs disease
• Traumatic surgery

• Iatrogenic causes
eg.cementitis

• Soft tissue defects

at area of
implantation
 Pathogenesis :
Plaque accumulation around implant

Inflammatory cells infiltrate in the connective tissue

Apical migration of plaque

Visible destructive changes around the implants

 Loss of osseointegration around neck of
Combination implant
of bacteria
and related and loading
bone loss
related bone loss

Bone loss progress

 Classification :
According to Froum and Rosen,2012
Early PD ≥4 mm (bleeding and/or suppuration on
probing)
Bone loss <25 % of implant length

moderate PD ≥6 mm (bleeding and/or suppuration on

probing)
Bone loss <25–50 % of implant length

severe PD ≥8 mm (bleeding and/or suppuration on

probing)
 Classification of peri implant
According to Spiekerman bone loss:
Class 1 Slight horizontal bone loss with
mimimum peri implant defect.
Class 2 Moderate horizontal bone loss with
isolated vertical defect.
Class 3 Moderate to advanced horizontal bone
loss with broad circular bony defect
Class 4 Advanced horizontal bone loss with broad
circumferential vertical defects as well as
loss of oral and/or vestibular bony wall
 Clinical features:

• Progressive increase in probing depth

• Suppurations and exudation from peri-

implant space

• Bleeding on probing
• Clinical appearance of inflamed tissue
(bleeding, swelling, color change,
suppuration, and plaque/calculus
accumulation)

• Progressive loss of supporting bone on

follow-up radiographs
 Implant on 36 2 years
ago

Bone loss around implant

of 36 after 2 years
 Histopathology:
 Microscopic examination revealed large
inflammatory cells infiltrate in mucosa.

 According to study conducted by Piatelli

et al.(1998) on 230 retrived implants
due to periodontitis ; major inflammatory
cells were macrophages, lymphocytes and
plasma cells in connective tissues.
 Diagnosis :

Diagnosis done basis of clinical and

radiological evaluation.
Diagnostic criterias :

 Clinical assessement

 Peri-implant probing

 Peri-implant radiography
Clinical assessment includes:
• Swelling redness of peri-implant
tissue from infection.

• Evaluation of plaque accumulation

around implant tissue.
• Suppuration (as sign of
inflammation).

• Mobility (indication of lack of osseo-

integration).
(mobility is detectable in final stages
only)
Fig. Redness of peri-implant tissue and calculus
build up
Fig : Circumferential bone defect around implant
 Peri-implant probing:
• Probing with blunt,
straight plastic periodontal
probe.

• Assessement of probing
depth, hyperplasia,
recession, bleeding and
supparation.

• Probing depth of 4 mm or Fig : Plastic probe

inserted around an
more is suggestive of peri- implant abutment
implant disease.
 Peri-implant radiography :
• Assessment of bone loss around
implant.

• In conventional radiographs, minor

changes in bone morphology may not
be noticed until they reach significant
size.

• Digital subtraction radiography increases

the sensitivity and has been successfully
applied.
Fig . Bone loss around implant in Fig . Pocket
function formation showing
‘pot hole’ like defect
 Prevention :
 Prevention is our
main goal.

• Regular dental visit.

• Education.
Fig: Removal of plaque
deposits with plastic scaler
Prevention (contd) :

• Plaque control procedures around

implants.

• Routine radiograph.

• Mechanical instrumentation of
affected areas possessing surgical flap
access should be performed.
 Criteria for succesful implant:
 According to Albrektsson et.al,1986

• The implant is immobile.

• Absence of peri-mplant radiolucency.

• Absence of pain ,infection ,neuropathy or

paraesthesia.

• At 1 year in function, <0.2mm vertical

 Management :

 Peri-implantitis is managed by
using specific treatment strategies,
depending on etiology of problem.
 Mombelli has suggested five considerations in therapy of peri implantitis

Mombelli has suggested five considerations in therapy of peri implantitis:

• Removal of the bacterial bio-film in the

peri-implant pocket.

• Decontamination and conditioning of the

surface of the implants.
• Correction via reduction and
elimination of sites that cannot be
adequately maintained by oral hygiene
procedure.

• Establishment of effective plaque

control regime.

•
Treatment of peri-implantitis
is divided into:
 Initial therapeutic phase.

 Surgical phase.

 Maintainance.
Initial therapeutic phase :
 Occlusal therapy

 Anti-infective therapy

 Systemic antibiotics

 Implant surface preparation

 Occlusal therapy :
• Excessive force leads to peri-
implant bone loss.

• Change in prosthesis design.

• Improvement in implant number

and position.
 Anti-infective therapy :
• Removal of
plaque deposits
with plastic
instruments.

• Polishing of all
accessible surface Debridement of peri-implant
with pumice. biofilm using a plastic curette.
• Irrigation of pockets with help of
0.12% chlorhexidine or local
antimicrobials.

• May be sufficient for

reestablishing periodontal health
or may be followed by surgical
phase.
Systemic antibiotics :
• Lang et al. suggest following
antibiotic regimes:
 systemic ornidazole 500 mg bd for 10
days or metronidazole 250 mg td for 10
days or a once daily combination of
metronidazole 500 mg and amoxicillin
375 mg for 10 days. 
• it appears that shallow peri-implant
infection may be successfully
controlled using antibiotics.

• But it is still open to question

whether deeper peri-implant lesions
can be adequately treated non-
surgically by a combination of a
local antibiotic and mechanical
debridement.
Implant surface preparation :
•By the use of air powder abrasive
which is mixture of sodium
bicarbonate and sterile water.

•Can also be done by application of

tetracycline HCL for 30 to 60 secs.

•Recently CO2 lasers have been

introduced.
 Surgical phase:
 Peri-implant resective therapy.

 Peri-implant regenerative
therapy.

 Re-osseointegration.
Peri-implant resective therapy:

• Peri-implant lesions with horizontal

bone loss or moderate vertical bone
loss (<3mm) suitable for resective
therapy.

• Full thickness flap raised to access

surgical area.
• Degranulation of
defect.

• Bone around
implant is re-
contoured if
required.

• Implant surface
prepared,
repositioned apically
and sutured.
Peri-implant regenerative therapy:
• Use of guided bone regeneration in
cases of moderate to deep vertical
defects.

• Removal of granulation tissues after

elevation of flap.
• Use of bone graft and barrier
membrane.

• membrane extended 3-4 mm

beyond defect and flap is closed.
Fig. Peri-implant regenerative Fig. Guided bone regeneration
therapy using titanium
granules
Re-osseoinegration :
• Main objective is denovo bone
formation at site where has
lost its osseo-integration.

• Increase in height of bone leads

to marginal shift of mucosa and
enchances soft tissue esthetics.
 Maintaince :
 By patient:
• Plaque control methods.

• Tooth brush with soft round

filaments.

• Dentrifices other cleaning agents

should not be used.
• Yam or gauge strips floss threader
used to clean crossbar of
subperiosteal implant and proximal
surface of abutments.

• Irrigators
 By therapist :

• Recall visit
at 3 months for 1st
year and on semi annual basis.

• Evaluation of oral hygiene.

• Occlusal harmony.
• Implant and prosthesis stability.

• overall soft and hard peri-implant

tissue health.

• Radiographic evaluation.
 Conclusion:
 Peri-implantitis is an inflammatory process affecting
tissues around an osseointegrated implant in function,
resulting in loss of supporting bone.

 Micro organisms play major role in this disease,

particularly gram negative anaerobic bacteria.

 Progression of peri-implantitis may lead to loss of

implant.

 It is reasonable to attempt the interception of

destructive peri-implantitis as early as possible and to
stop its progression by the removal of bacterial deposits.
 References :
• Carranza’s clinical periodontology; 11th edition
• Clinical periodontology and implant dentistry -5th edition
• Definition, etiology, prevention and treatment of peri-implantitis –
a review Ralf Smeets, Anders Henningsen, [...], and Jamal M
Stein
• Management of peri-implantitis: a systematic review, 2010–2015,
Nisha Mahato, Xiaohong Wu and Lu Wang
• Management of peri-implantitis; dental research journal 2012 sep-
oct by Jayachandran Prathapachandran and Neethu Suresh;
PubMed
• Journal of canadian dental association
• Peri-Implantitis: A Risk Factor In Implant Failure, a review article;
Hemant kumar Gupta, Amit Garg, Navjot Kaur Bedi; www.jcdr.net
• Periodontics revisited; Shalu Bathla, MDS; Manish Bathla, MD