PERI-IMPLANTITISPERI-IMPLANTITIS

INTRODUCTIONINTRODUCTION Developing artificial replacements for missing teeth Developing artificial replacements for missing teeth

has been an elusive goal for more than 1500 years.has been an elusive goal for more than 1500 years.

The present surge in the use of implants was The present surge in the use of implants was initiated in initiated in 1952 by Branemark1952 by Branemark

Branemark & associates described the relationship Branemark & associates described the relationship b/n titanium & bone for which they coined the term b/n titanium & bone for which they coined the term Osseointegration, as the “ direct structural & , as the “ direct structural & functional connection b/n ordered ,living bone & functional connection b/n ordered ,living bone & the surface of a load carrying implant.the surface of a load carrying implant.

PERI IMPLANT MUCOSAPERI IMPLANT MUCOSA The mucosal tissues around The mucosal tissues around

intraosseous implants form a intraosseous implants form a tightly adherent band tightly adherent band consisting of a collagenous consisting of a collagenous lamina propria covered by lamina propria covered by stratified squamous keratinised stratified squamous keratinised epithelium. epithelium.

The implant epithelium The implant epithelium junction is analogous to the junction is analogous to the junctional epithelium around junctional epithelium around natural teeth, in that the natural teeth, in that the epithelial cells attach to the epithelial cells attach to the titanium implant by means of titanium implant by means of hemidesmosomes and basal hemidesmosomes and basal lamina.lamina.

Clinically normal gingival mucosa next to 2 implants. Normal epithelium lining the implantafter removal of the cover screw.

- A sulcus forms around the implant lined with a A sulcus forms around the implant lined with a sulcular epithelium.sulcular epithelium.

- Capillary loops in the CT under the junctional & Capillary loops in the CT under the junctional & sulcular epithelia appear to be anatomically similar sulcular epithelia appear to be anatomically similar to those found in the normal periodontium to those found in the normal periodontium

-The depth of a normal noninflamed or minimally The depth of a normal noninflamed or minimally inflamed sulcus around an intraosseous implant has inflamed sulcus around an intraosseous implant has not been accurately determined but is assumed to be not been accurately determined but is assumed to be between 1.5 to 2.0 mm.between 1.5 to 2.0 mm.

-Collagen fibers are nonattached & run parallel to Collagen fibers are nonattached & run parallel to the implant surface owing to the lack of cementum. the implant surface owing to the lack of cementum.

-This is an important difference between peri This is an important difference between peri implant & periodontal tissues.implant & periodontal tissues.

IMPLANT-BONE INTERFACEIMPLANT-BONE INTERFACEThe relationship b/n endosseous implants & boneThe relationship b/n endosseous implants & boneconsists of one of 3 mechanisms.consists of one of 3 mechanisms.1)1) Osseointegration where the bone is in intimate but Osseointegration where the bone is in intimate but

not ultra structural contact with the implant not ultra structural contact with the implant 2)2) Fibrosseous integration in which soft tissues such Fibrosseous integration in which soft tissues such

as fibers & /or cells are interposed b/n the 2 as fibers & /or cells are interposed b/n the 2 surfaces surfaces

3)3) Biointegration, which denotes a direct biochemical Biointegration, which denotes a direct biochemical bond of the bone to the surface of an implant at the bond of the bone to the surface of an implant at the electron microscopic level & is independent of any electron microscopic level & is independent of any mechanical inter locking system. [eg: Bonding of mechanical inter locking system. [eg: Bonding of HA to boneHA to bone].].

- The osseointegration concept proposed by The osseointegration concept proposed by Branemark et alBranemark et al & called functional ankylosis by & called functional ankylosis by SchroederSchroeder states that there is absence of CT or any states that there is absence of CT or any tissue in the interface b/n the implant & the bone. tissue in the interface b/n the implant & the bone.

- It is important to note that osseointegration refers to It is important to note that osseointegration refers to the direct contact of bone & implant at the light the direct contact of bone & implant at the light microscopic level.microscopic level.

- Successful cases have b/n 30% & 95% of the Successful cases have b/n 30% & 95% of the implant surface, as measured by light microscopy , implant surface, as measured by light microscopy , in contact with bone.in contact with bone.

CRITERIA FOR IMPLANT SUCCESS INCLUDECRITERIA FOR IMPLANT SUCCESS INCLUDE

1)1) Absence of signs/symptoms such as pain, Absence of signs/symptoms such as pain, infection, neuropathies, parathesia & violation of infection, neuropathies, parathesia & violation of vital structuresvital structures

2)2) Implant immobilityImplant immobility

3)3) No continuous peri implant radiolucencyNo continuous peri implant radiolucency

4)4) Negligible progressive bone loss(less than 0.2mm Negligible progressive bone loss(less than 0.2mm annually) after physiologic remodelling during the annually) after physiologic remodelling during the first year of functionfirst year of function

5)5) Patient/dentist satisfaction with implant supported Patient/dentist satisfaction with implant supported restoration.restoration.

PERI IMPLANT DISEASEPERI IMPLANT DISEASE

Despite the long-term predictability ofDespite the long-term predictability of

Osseointegrated implants, biologic, biomechanical &Osseointegrated implants, biologic, biomechanical &

esthetic complication can occur in a small percentageesthetic complication can occur in a small percentage

of cases.of cases.

Pathologic changes of the peri-implant tissues can Pathologic changes of the peri-implant tissues can be placed in the general category of periimplant be placed in the general category of periimplant disease. disease.

- Peri-implant mucositis-Peri-implant mucositis- Inflammatory changes that Inflammatory changes that are confined to the soft tissue surrounding an are confined to the soft tissue surrounding an implant.implant.

- Peri implantitisPeri implantitis is defined as an inflammatory is defined as an inflammatory process affecting the tissues around an process affecting the tissues around an osseointegrated implant in function, resulting in loss osseointegrated implant in function, resulting in loss of supporting bone. of supporting bone.

- Progressive peri implant bone loss in conjunction Progressive peri implant bone loss in conjunction with a soft tissue inflammatory lesion is termed with a soft tissue inflammatory lesion is termed peri peri implantitis.implantitis.

Early implant failures are the result of events that mayEarly implant failures are the result of events that may

jeopardize or prevent Osseointegration from occurring &jeopardize or prevent Osseointegration from occurring &

include:include:

1) Improper preparation of the recipient site, which1) Improper preparation of the recipient site, which

results in undue hard tissue damage such asresults in undue hard tissue damage such as

necrosis of the bone.necrosis of the bone.

2) Bacterial contamination & extensive inflammation2) Bacterial contamination & extensive inflammation

of the wound that may delay healing of the soft & hardof the wound that may delay healing of the soft & hard

tissues.tissues.

3) Improper mechanical stability of the implant following its3) Improper mechanical stability of the implant following its

insertion.insertion.

4) Premature loading of the implant.4) Premature loading of the implant.

- Late failures occur in situations during whichLate failures occur in situations during which

osseointegration of a previously stable & properlyosseointegration of a previously stable & properly

functioning implant is lost. functioning implant is lost.

- that late failures are the result of excessive load that late failures are the result of excessive load & /or infection.& /or infection.

ETIOLOGY OF PERI IMPLANTITISETIOLOGY OF PERI IMPLANTITIS- Bacterial infection Bacterial infection - Biomechanical factors.Biomechanical factors.

1) Bacterial infection1) Bacterial infection- If plaque accumulates on the implant surfaces, the subIf plaque accumulates on the implant surfaces, the sub

epithelial connective tissue becomes infiltrated by largeepithelial connective tissue becomes infiltrated by large

number of inflammatory cells & the epithelium appearsnumber of inflammatory cells & the epithelium appears

ulcerated & loosely adherent.ulcerated & loosely adherent.- When the plaque front continues to migrate apically, theWhen the plaque front continues to migrate apically, the

clinical & radiographic signs of tissue destruction are seenclinical & radiographic signs of tissue destruction are seen

around both implants & teeth; however the size of the softaround both implants & teeth; however the size of the soft

tissue inflammatory lesion & the bone loss is larger aroundtissue inflammatory lesion & the bone loss is larger around

implants.implants.

- One reason for the increased inflammation around One reason for the increased inflammation around an implant might be the low-vascularity soft tissue an implant might be the low-vascularity soft tissue band and the difference in collagen/fibroblast ratio band and the difference in collagen/fibroblast ratio of gingival tissues, which affects the defense of gingival tissues, which affects the defense mechanisms around an implant as compared with mechanisms around an implant as compared with those seen in tissues around teeth with a periodontal those seen in tissues around teeth with a periodontal ligament.ligament.

BIOMECHANICAL FACTORSBIOMECHANICAL FACTORS

- excessive biomechanical forces may lead to high - excessive biomechanical forces may lead to high stress or micro-fractures in the coronal bone to stress or micro-fractures in the coronal bone to implant contact & thus lead to loss of implant contact & thus lead to loss of osseointegration around the neck of the implant.osseointegration around the neck of the implant.

The role of overloading is likely to increase in fourThe role of overloading is likely to increase in four

clinical situations:clinical situations:

1.1. The implant is placed in poor quality bone.The implant is placed in poor quality bone.

2.2. The implant’s position or the total amount of implants The implant’s position or the total amount of implants placed does not favor ideal load transmission over the placed does not favor ideal load transmission over the implant surface.implant surface.

3.3. The patient has a pattern of heavy occlusal function The patient has a pattern of heavy occlusal function associated with parafunction.associated with parafunction.

4.4. The prosthetic superstructure does not fit the implants The prosthetic superstructure does not fit the implants precisely.precisely.

Other etiological factorsOther etiological factors traumatic surgical procedures, traumatic surgical procedures,

smoking, inadequate amount of bonesmoking, inadequate amount of bone at placement,at placement,

compromised host response can act as co-factors in thecompromised host response can act as co-factors in the

development of peri implant disease.development of peri implant disease.

FEATURES AND FREQUENCYThe following signs & symptoms are typical for peri-implantitis lesions:-There is radiological evidence for vertical destruction of the crestal bone. The defect usually assumes the shape of a saucer around the implant while the bottom part of the implant retains perfect osseointegration. In some instanceswedge-shaped defects develop along the implant. Whether specific patterns of marginal bone loss indicate a specific underlying cause is not known. Bone destruction may proceed without any notable signs of implant mobility until osseointegration is completely lost. A continuous periimplant radiolucency indicates implant failure

-Vertical bone destruction is associated with the formation of a peri-implant pocket.

-There is bleeding after gentle probing with a blunt instrument and there may be suppuration from the pocket.

-Tissues may or may not be swollen. Hyperplasia is frequently seen if implants are located in an area with nonkeratinized mucosa or if the suprastructure is an overdenture.

-Pain is not a typical feature of peri-implantitis.

Diagnosis of Peri implant tissue breakdownDiagnosis of Peri implant tissue breakdown

1) Peri implant probing1) Peri implant probing -To diagnose a compromised implant -To diagnose a compromised implant site, soft tissue measurements using manual or automated site, soft tissue measurements using manual or automated probes have been suggested. probes have been suggested.

(measure of soft tissue hyperplasia (measure of soft tissue hyperplasia

or recession)or recession)- Bleeding after probing & Bleeding after probing & - Exudation & suppuration from the peri-implant space Exudation & suppuration from the peri-implant space

2) MOBILITY2) MOBILITY- Implant mobility is an indication for lack of Implant mobility is an indication for lack of

osseointegrationosseointegration

- Even if disease conditions in the peri-implant tissues have Even if disease conditions in the peri-implant tissues have progressed relatively far, implants may still appear progressed relatively far, implants may still appear immobile due to some remaining direct bone to implant immobile due to some remaining direct bone to implant contact.contact.

- Thus mobility is insensitive in detecting the early stages of Thus mobility is insensitive in detecting the early stages of peri-implant disease.peri-implant disease.

- The parameter serves to diagnose the final stage of The parameter serves to diagnose the final stage of osseodisintegration & may help to decide that an implant osseodisintegration & may help to decide that an implant has to be removed .has to be removed .

- Implant mobility indicates the final stage of peri-implant disease, characterized by complete loss of the direct bone to implant interface.

- For interpretation of low degrees of mobility an electronic For interpretation of low degrees of mobility an electronic device has been designed to measure the damping device has been designed to measure the damping characteristics of the periodontium of natural teeth- characteristics of the periodontium of natural teeth- PeriotestPeriotest

3) SUPPURATION3) SUPPURATION

- Suppuration is associated with disease activity & Suppuration is associated with disease activity & indicates a need for anti-infective therapy.indicates a need for anti-infective therapy.

4) CLINICAL INDICES4) CLINICAL INDICES Swelling & redness of the marginal tissues have been Swelling & redness of the marginal tissues have been

reported form peri-implant infections in addition to pocket reported form peri-implant infections in addition to pocket formation, suppuration & bleeding.formation, suppuration & bleeding.

5) PERI IMPLANT RADIOGRAPHY 5) PERI IMPLANT RADIOGRAPHY

- For accurate assessments of bone level changes , For accurate assessments of bone level changes , longitudinal series of standardized radiographs are longitudinal series of standardized radiographs are required.required.

- Detection of minute changes of bone level or Detection of minute changes of bone level or density requires a reproducible projection geometry density requires a reproducible projection geometry for the x- ray beam ,provided by an appropriate for the x- ray beam ,provided by an appropriate aiming device.aiming device.

6) MICROBIOLOGY 6) MICROBIOLOGY - Bacterial culture, DNA probes, polymerase chain Bacterial culture, DNA probes, polymerase chain

reaction, monoclonal antibody & enzyme assays to reaction, monoclonal antibody & enzyme assays to monitor the sub gingival flora have been proposed monitor the sub gingival flora have been proposed to determine an elevated risk for periodontal disease to determine an elevated risk for periodontal disease or peri-implantitis.or peri-implantitis.

INITIAL PHASE OF PERI IMPLANTITIS INITIAL PHASE OF PERI IMPLANTITIS TREATMENTTREATMENT

Occlusal therapyOcclusal therapy

- When occlusal forces are considered the main - When occlusal forces are considered the main etiologic factor for periimplant bone loss, treatment etiologic factor for periimplant bone loss, treatment involves an analysis of the fit of the prosthesis, the involves an analysis of the fit of the prosthesis, the number & position of the implants & an occlusal number & position of the implants & an occlusal evaluation. Prosthesis design changes, improvement evaluation. Prosthesis design changes, improvement of implant number & position & occlusal of implant number & position & occlusal equilibration can contribute to arrest the progression equilibration can contribute to arrest the progression of peri implant tissue breakdown.of peri implant tissue breakdown.

NON SURGICAL THERAPYNON SURGICAL THERAPYIndicationsIndications- MucosalMucosal inflammation detected by clinical signsinflammation detected by clinical signs- Radiographic bone level stable.Radiographic bone level stable.

Involves 1) the local removal of plaque deposits withInvolves 1) the local removal of plaque deposits withplastic instruments & polishing of all accessibleplastic instruments & polishing of all accessiblesurfaces with pumice, surfaces with pumice, 2) sub-gingival irrigation of all peri implant pockets with a2) sub-gingival irrigation of all peri implant pockets with a0.12% Chlorhexidine, 0.12% Chlorhexidine, 3) systemic antimicrobial therapy for 10 consecutive days &3) systemic antimicrobial therapy for 10 consecutive days &4) improved patient compliance with oral hygiene until a4) improved patient compliance with oral hygiene until ahealthy peri implant site is established.healthy peri implant site is established.

Mechanical devicesMechanical devices- Mechanical instrumentation may damage the implant Mechanical instrumentation may damage the implant

surface if performed with metal instruments harder than surface if performed with metal instruments harder than titanium. titanium.

- The method of choice involves the use of a high- pressure The method of choice involves the use of a high- pressure air powder abrasive (mixture of sodium bicarbonate & air powder abrasive (mixture of sodium bicarbonate & sterile water). sterile water).

- This method removes microbial deposits completely, does This method removes microbial deposits completely, does not change the surface topography & does not adversely not change the surface topography & does not adversely affect the cell adhesion.affect the cell adhesion.

Chemo therapeutic agentsChemo therapeutic agents- Use of a supersaturated solution of Use of a supersaturated solution of

citric acid for 30-60 seconds has the citric acid for 30-60 seconds has the highest potential for removal of highest potential for removal of endotoxins from both Hydroxy endotoxins from both Hydroxy apatite- & titanium implant surfaces.apatite- & titanium implant surfaces.

- Irradiation with a soft laser for Irradiation with a soft laser for elimination of bacteria associated with elimination of bacteria associated with Peri implantitis has also shown Peri implantitis has also shown promising results in the destruction of promising results in the destruction of bacterial cells.bacterial cells.

SURGICAL TECHNIQUESSURGICAL TECHNIQUES- Once the inflammatory process in the periimplant Once the inflammatory process in the periimplant

tissues is under control, an attempt may be made to tissues is under control, an attempt may be made to improve or reestablish osseointergration.improve or reestablish osseointergration.

- The surgical techniques advocated to control The surgical techniques advocated to control periimplant lesions are modified from techniques periimplant lesions are modified from techniques used to treat bone defects around teeth.used to treat bone defects around teeth.

ADVANCED TYPE IV

BONE LOSS AROUND

IMPLANTS

- The regenerative therapy is also used to reduce The regenerative therapy is also used to reduce pockets with the ultimate goal of regeneration of pockets with the ultimate goal of regeneration of lost bone tissuelost bone tissue

- To accomplish regeneration of lost bone tissue & To accomplish regeneration of lost bone tissue & reosseointegration, Guided bone regeneration & reosseointegration, Guided bone regeneration & bone graft techniques have been suggested.bone graft techniques have been suggested.

- The GBR principle using a non-resorbable e PTFE The GBR principle using a non-resorbable e PTFE membrane has been used for healing of bone membrane has been used for healing of bone defects seen at the time of implant placement & defects seen at the time of implant placement & around failingaround failing implants.implants.

IMPLANT MAINTENANCEIMPLANT MAINTENANCECUMULATIVE INTERCEPTIVE SUPPORTIVE THERAPYCUMULATIVE INTERCEPTIVE SUPPORTIVE THERAPY The principle of this method is to detect periimplant The principle of this method is to detect periimplant

infections as early as possible & to intercept the problems infections as early as possible & to intercept the problems with appropriate therapy.with appropriate therapy.

The basis for this system is a regular recall of the implant The basis for this system is a regular recall of the implant patient & the repeated assessment of the following key patient & the repeated assessment of the following key parameters around each implant.parameters around each implant.

a)a) The presence of plaqueThe presence of plaque

b)b) The bleeding tendency of the periimplant tissuesThe bleeding tendency of the periimplant tissues

c)c) SuppurationSuppuration

d)d) Presence of periimplant pocketsPresence of periimplant pockets

e)e) Radiological evidence of bone loss.Radiological evidence of bone loss.