Peri-implantitis symptoms and treatment. Clinical manifestations of peri-implantitis and perimucositis in modern dental practice

Damaging tissue around the implant. Inflammation develops due to the penetration of pathogenic microorganisms into the area between the titanium root and the gum. If treatment for peri-implantitis is not started at the initial stage, the process will take a chronic form.

In advanced cases, the gums become loose and a gum canal is formed, gradually increasing in size. Over time, food debris, microbes and saliva accumulate in the gum pocket, extensive suppuration begins, resulting in the destruction of bone tissue.

The discharge of pus at the site of installation of the dental structure may also indicate the beginning of the rejection process implanted titanium root- non-acceptance by the jaw bone.

Pus can be released through a fistula formed in the area of the implant, or it can flow directly from under the dental system when pressing on the gums.

Why did pus form?

The reason for the appearance of pus around the implant depends on what kind of complication this white or green discharge is a sign of.

If suppuration is caused by peri-implantitis

The reason may be:

Penetration of bacteria into bone tissue during implantation of the structure or after implantation.
Failure to comply with the rules of oral hygiene during the period of engraftment of the titanium rod.
Formation of a hematoma between the gum and supragingival plug.
The formation of an excessively large bed under the implant, which causes its mobility and facilitates the penetration of bacteria.
Displacement or damage to the dental system as a result of mechanical stress or excessive stress.
Injury to the wall of the appendages of the nasal cavity (paranasal sinuses).
Making a mistake when closing a postoperative wound.
The presence of an inflammatory process in neighboring teeth.
Inaccurate production of the prosthesis.

Initial stage of purulent inflammation above the implant

If the gums near the implant begin to fester due to rejection of the structure

The reasons for the development of complications may be the following:

Peri-implantitis.
Insufficient bone volume.
Deterioration of health - exacerbation of chronic ailments.
Allergic reaction to the implant material.
Use of low-quality or counterfeit implants and instruments.
The implantologist made a mistake:

selection of an implant model of the wrong size;
failure to comply with sterility conditions during implantation;
tissue necrosis caused by overheating of the instrument when drilling a bed for an implant in the jawbone;
installing an artificial root in the wrong position;
carrying out implantation in the presence of foci of inflammation in the oral cavity;
incomplete examination of the patient’s medical history, as a result of which existing contraindications were not identified.

Patient's failure to comply with doctor's recommendations:
visiting a bathhouse, diving into an ice hole;
concealing from the implantologist the presence of any health problems - even it seemed that the most insignificant pathologies could adversely affect the result of the operation;
self-prescription or refusal to take medications;
insufficient oral hygiene;
smoking after implant installation - according to statistics, implant rejection occurred in 30% of smoking patients in the first five years.

What additional symptoms indicate inflammation?

The development of an inflammatory process in the area of the implant is indicated not only by the release of pus, but also by the following symptoms:

The occurrence of severe pain that can spread throughout the mouth;
swelling and redness of the gums;
appearance and enlargement of the gum pocket;
the appearance of blood in the area where the implant is placed;
mobility of the artificial root.

How to treat a complication

Treatment of peri-implantitis depends on the stage of development of the disease. Reduces to the following procedures:

surgical removal of the sac containing pus;
cleaning and removing the gum pocket;
treating gums with antiseptics;
removal of tartar and soft plaque formed on the crown using ultrasound, which also has a detrimental effect on pathogenic bacteria;
if necessary, clean and disinfect the dental structure using a special device;
the patient is recommended to actively rinse the mouth with antibacterial solutions and infusions of medicinal herbs.

Removal of damaged periodontal pocket tissues

When acute tissue destruction is diagnosed, after removing the lump with pus, the jaw bone and normal microflora of the oral cavity are restored. Thus, without removing the implant, it is possible to perform an operation to replant shavings from artificial bone or donor natural material. After surgery, the wound is covered with stitches and a bandage. The patient is prescribed the use of Diplen-dent film, Metrogil-dent gel, and Solcoseryl dental adhesive paste.

To restore the tissues affected around the titanium root and speed up the process of relieving inflammation, physiotherapeutic procedures are carried out. Laser treatment is especially effective. Antibiotics are also prescribed.

If the inflammatory process and suppuration recur, the only option left is removal of the implant. Removal of the dental structure is also resorted to in the event of the development of the process of its rejection.

Can re-implantation be performed after treatment?

In almost all cases, after treatment of the inflammatory process and cessation of purulent discharge, re-implantation is possible. But after removing the implant, no more than 1-2 months should pass, otherwise the jaw, without receiving the necessary load, will begin to atrophy.

If there is insufficient amount of bone tissue, surgery may be prescribed to increase it. Re-implantation is carried out after restoration of injured tissue.

What to do to prevent complications after implantation

To begin with, you should carefully choose the clinic where the implantation will be performed. Dentistry must have modern equipment and work with high-quality, proven dental systems, the manufacturers of which do not raise the slightest doubt. Doctors in the clinic must have the necessary skills, knowledge and experience. When choosing a dentist and implantologist, you should carefully study the reviews of real patients of the clinic.

For preventive purposes, you must visit the dentist at least every six months. If any discomfort or symptoms of the development of pathological processes occur, a visit to the dentist should be immediate.

After implantation, you should stop drinking alcohol, smoking, and avoid any mechanical damage to the gums, cheeks and jawbone. After implantation and a year after the operation, an x-ray should be taken, this will allow timely detection of jaw atrophy.

You need to brush your teeth twice a day, and you shouldn’t limit yourself to a regular toothbrush. To clean the oral cavity, dentists recommend using an irrigator, whose operating principle is to remove food debris and bacteria from the interdental spaces and periodontal folds using strong water pressure. Electric, ultrasonic and ionic toothbrushes will help to effectively clean the oral cavity.

Doctors' opinion

Arkady Petrovich Androkhonin

“After implantation, swelling, pain and bleeding of the postoperative wound may occur. However, normally these symptoms should not get worse over time and should go away within a week at most. If the above symptoms bother you for a longer period of time, you should seek medical help. If there is pus on the sutures or near the implant, this indicates the development of an inflammatory process and the presence of a serious risk of rejection of the structure.”

In the absence of timely diagnosis and adequate comprehensive treatment, the pathology leads to resorption (progressive loss) of bone tissue, implant mobility and, ultimately, loss of the structure.

According to various data, peri-implantitis develops in 12-43% of cases.

Causes of peri-implantitis

Causes of the disease include:

odontogenic infection;
medical errors during the implantation procedure;
low quality construction (extremely rare);
formation of subgingival hematoma with subsequent suppuration;
low level of oral hygiene.

If in the immediate postoperative period peri-implantitis is caused mainly by a violation of the implant placement technology, then in the long term, the banal failure of the patient to comply with basic hygiene rules comes first.

Medical errors are violations of the rules of asepsis and antisepsis, incorrect selection of an intraosseous fragment, as well as incorrectly manufactured orthopedic structures, leading to local overload and, as a consequence, chronic injury of periodontal tissues. Other mistakes by the dentist include the presence of microscopic gaps between the implant and the abutment, as well as disruption of the integrity of bone structures due to excessive force during the screwing process and inadequate suturing of the soft tissue incision.

You should follow all the instructions of your doctor, take measures to strengthen general and local immunity, promptly sanitize foci of chronic infection (especially in the oral cavity and nasopharynx), and also stop smoking.

Plisov Vladimir, dentist, medical columnist

Dental implantation has been practiced in dentistry for decades, but complications after such a procedure they still arise.

One of the most common complications is peri-implantitis.

This disease appeared along with the practice of implantation, however, getting rid of it is not so difficult with the help of an experienced specialist.

What is peri-implantitis?

Peri-implantitis is called inflammatory process, which can occur in the bone and soft tissue surrounding the implant. The bone tissue becomes thinner and destroyed.

Inflammation may appear both after prosthetics and after a long period of time, after many years. During peri-implantitis, dental the implant is rejected by the body.

Experts say that peri-implantitis occurs in 16% of patients.

Watch a video with details about peri-implantitis and other problems that patients face with implants in the mouth:

Causes and development of the disease

The causes of the disease may include various factors. Experts highlight three categories of reasons that lead to peri-implantitis:

Low quality materials and tools;
Medical errors;
Improper oral care after the procedure.

More than three hundred species various bacteria may cause peri-implantitis. If an oral infection has not been treated before the procedure, complications are likely to occur.

After implantation, the patient must visit the doctor frequently. He recommends special oral care products.

If the patient does not properly care for the oral cavity, peri-implantitis cannot be avoided. It is very important to remember the advice of a specialist, rules of oral care.

The disease can occur in absolutely any patient; no one is immune from this. However, with proper oral care and visiting a doctor, the likelihood of peri-implantitis is decreasing.

If a specialist used low-quality tools and materials during work, peri-implantitis will occur. To avoid this, it is recommended to contact verified dental clinics.

Diagnosis of the disease

Diagnosis is carried out using visual and instrumental examination patient's oral cavity.

The doctor examines swelling and hypermia of the mucous membrane. Experts assess the condition of the peri-implant gums using stomatoscopy.

Other methods are also used Definitions of peri-implantitis:

Periapical radiography, in which the root level can be known immediately after loading.
Probing groove areas under slight pressure.
Dental scanning with application tomograph. This is a useful diagnostic method because it can identify peri-implant lesions from different angles.
During diagnosis, bacteriological, biochemical laboratory research. Polymerase chain reaction is also used by specialists. These methods are effective and allow you to determine peri-implantitis.

Peri-implantitis and its symptoms

Symptoms of this disease include:

Redness, swelling of the gums;
Pain in the area where the implant is installed;
Patients' gums may;
If the disease is present, there will be obvious discomfort in the oral area.

Experts say that pain after the procedure can be for three days, this is the norm.

However, if the patient still feels pain after 4-5 days, you should consult a doctor. This may be a sign of peri-implantitis.

Treatment of the disease

Peri-implantitis — serious illness, which does not have a natural etiology, so it is very important to make a timely diagnosis and begin the correct treatment.

Traditional methods

Dentists remind you that it is not possible to get rid of this disease at home.

The photo on the left shows peri-implantitis at the initial stage, but even here it is impossible to cure it with rinses and lotions.

The process of bone resorption requires immediate intervention by an experienced specialist.

The specialist must examine the patient’s oral cavity and determine which treatment method will be optimal.

After carrying out the necessary treatment procedures in the dentist’s office, you can natural antiseptics. Experts recommend rinsing your mouth with chamomile decoction.

Treatment with medications

This type of treatment includes several groups of drugs:

Antiseptics. Such products are used to rinse the mouth and wash fistula tracts.
Antibiotics. Specialists prescribe agents that penetrate the soft tissues and bone structures of the jaw.
Non-steroidal anti-inflammatory drugs. With the help of such medications, inflammation is suppressed, pain and swelling are reduced, and the temperature decreases.
Antihistamines. The allergic component of inflammation disappears.

Among the most famous antiseptics Miramistin and Furacilin solution can be distinguished. Used in the treatment of this disease and such antibiotics, like Azithromycin, Josamycin.

Often prescribed by specialists antihistamines agents: Loratadine and Desloratadine. Among the non-steroidal anti-inflammatory drugs are: Ibuprofen, Ibuklin.

At the dentist's office

Treatment methods for this disease are selected depending on the stage of the disease.

First of all, a specialist eliminates inflammation, he is sanitizing the hearth.

An ozonated solution is used to irrigate the damaged pockets. Baths and applications can be performed.

In the dentist's office, soft deposits and deposits that may be on the surface of the crown are removed from the patient. Areas under the gum can be cleaned using ultrasound. The oral cavity thus becomes cleaner, pathogenic microorganisms are suppressed.

If the disease is at a severe stage, you have to resort to surgical methods.

The inflamed area is opened, and specialists remove the abscess. The implant is also thoroughly cleaned. In some cases, it is necessary to restore bone volume.

Treatment results

Dentists claim that treatment results appear for every person at different times.

For one patient, treatment may take a minimal amount of time, while for another it may take a very long time.

Treatment must be under the supervision of a doctor. Under no circumstances should you try to treat yourself, as this could make the situation worse.

In some cases, treatment of peri-implantitis does not bring results. The implant is rejected by the body, it has to be delete completely, and after that the patient undergoes long rehabilitation treatment.

During treatment, the patient should visit the dentist regularly, who will determine how the treatment is progressing. If treatment results really do not occur for a long time, the dentist makes a decision remove the implant.

In any case, the patient should not take any action on his own. Treat peri-implantitis It is impossible without an examination by a specialist.

Prevention

You need to regularly care for your mouth, teeth and implants. For this purpose, the patient purchases toothpastes and toothpastes recommended by specialists.
The patient must visit the dentist's office regularly.
If necessary, the patient must undergo special procedures in the dentist's office.
You need to treat implants very carefully, accurately and with care.
The patient should avoid physical damage to the implant. There is no need to put excessive stress on the implant.

Dental implantology is a very popular method of restoring the dentition and jaw system. Prosthetics with an implant is possible at almost any age, which significantly increases the number of patients using this method.

But sometimes implantation has some complications. The most common of them is peri-implantitis, which leads to dental implant failure.

Clinical studies have shown that this disease develops in 16% of patients.

Peri-implantitis is an inflammatory process in the bone and soft tissue surrounding the implant. It is characterized by progressive thinning and reduction, that is, destruction (resorption) of bone tissue, with its replacement by granulation tissue.

Inflammation can occur both immediately after prosthetics and after many years. If not treated in a timely manner, rejection and complete loss of the implanted prosthesis may occur.

Symptoms

Peri-implantitis is characterized by symptoms that distinguish it from other diseases:

the soft tissue around the implanted tooth swells and turns bright red;
bleeding of the gums in the tooth area appears;
in some cases, suppuration may occur with the formation of a fistula;
Detachment of the gum (gum pocket) of more than 1 mm occurs, while the gum itself becomes loose. Its depth increases;
pain often occurs around the implanted tooth;
mobility of the implant is observed;
at the junction, the bone becomes noticeably thinner.

Etiology

Peri-implantitis occurs for several reasons:

suppuration of a hematoma formed above the plug under the gum;
trauma in the area of the prosthetic tooth of a chronic nature or acquired during implantation;
disruption of the immune system;
diabetes;
drinking alcohol and smoking;
incorrectly selected implantation tactics;
failure to comply with proper hygienic requirements for the care of implants and ignoring regular clinical examinations by the dentist;
accession and progressive development of secondary infection;
implant of inappropriate quality and size;
heavy load or trauma to the implanted area;
unskilled work on prosthetics (medical error).

According to statistics, medical errors are the rarest cause of this disease. The most common cause is infection, as peri-implantitis can be caused by more than 300 bacteria.

Diagnostics

If the first symptoms of peri-implantitis occur, you should immediately consult a doctor who will conduct a diagnosis and determine the extent of this disease.

Diagnosis begins with a visual examination, palpation and probing of the problem area. Using stomatoscopy, the dentist identifies the area of inflammation and the condition of the soft tissues in this area.

To determine the degree of bone tissue damage, use:

Schiller-Pisarev test;
X-ray examination;
dental tomography;
orthopantomography.

Sometimes additional laboratory tests may be needed:

macrohistochemical;
bacterioscopic;
bacteriological;
cytological

Classification

There is a classification of peri-implantitis based on the clinical condition of the bone tissue at various stages of the disease.

I degree

Characterized by pronounced inflammation of the soft tissues around the prosthesis. The implant gains some mobility.

Horizontal thinning of the jawbone occurs, resulting in visual effect of narrowing of the gums at the site of implant installation. The gum pocket increases by 1 mm or more.

II degree

In degree II, in addition to the above symptoms, slight change in bone height. A minor defect forms in the area where the bone connects to the implant.

The depth of the pocket changes and gum detachment occurs. The prosthesis gains constant mobility.

III degree

Grade III is characterized by a significant decrease in the height of the jaw bone. Formed vertical defect along the entire length of the implant. The depth of the gum pocket increases, exposing the abutment. There is constant mobility of the prosthesis with acute pain.

IV degree

The latest degree is IV. Happening destruction of the alveolar process of the jaw bone. Complete rejection of the implant is possible.

Treatment

Two methods are used for treatment: non-surgical and surgical.

Non-surgical method

Non-surgical treatment is used only at the initial stage of the disease.

Operating procedure:

anesthesia is performed. If necessary, topical antibiotics are used;
the prosthesis supported by the implant is removed. They clean it and modify it;
using appropriate tools, ultrasonic nozzles, laser or sandblasting, granulation is removed and the surface of the implant and bed is sanitized;
install a modified prosthesis.

This method has a number of disadvantages:

there is no way to reduce the depth of the gum pocket;
upon probing, bleeding begins;
has low efficiency.

Surgical method

Surgical treatment of peri-implantitis is carried out only after non-surgical intervention in several main stages:

Depending on the degree of the disease, the stages of surgical treatment have their own characteristics.

Treatment of stage I and II disease

To treat inflammation of degrees I and II, one-stage implantation is mainly used. Operating procedure:

preparation of the oral cavity;
surgical incision of the gum along the alveolar process and its peeling to expose the bone bed;
removing the plug;
removal of granulation, sanitation of the bed and implant;
correction of the bone bed using cutters;
installing a plug;
isolation of the implant with a membrane;
suturing;
carrying out hemostasis;
prescription of anti-inflammatory therapy (antibiotics, antihistamines, antiseptics).

Inflammation after the procedures goes away within 4-14 days.

Treatment of stage III - IV disease

When treating grades III - IV, in addition to standard treatment, restoration (restoration) of the diminishing bone is carried out.

Operating procedure:

preparation of the oral cavity;
incision and peeling of the mucoperiosteal flap of the alveolar process;
trepanation of the cortical plate of the jaw;
implant removal;
cleaning and sanitation of the bed;
leveling and polishing the surface of the prosthesis;
carrying out implantoplasty for targeted restoration of bone tissue dimensions;
membrane insulation;
suturing;
prescription of anti-inflammatory treatment;
reimplantation.

Reimplantation into the previous bed with the same type and size of implant should be carried out no earlier than 4-6 months after implantoplasty.

The use of a larger two-stage implant allows its installation in the previous bed within 1 month. Replantation in a bed located next to the previous one after 3 weeks.

In the next video we will be told in detail about the brushes for the treatment of peri-implantitis HANS NiTi:

Forecast

With high-quality installation of a repeat implant, most patients are satisfied with the resulting design and do not have any complications.

Most often, peri-implantitis affects the anterior part of the lower jaw. In this case, several implants located nearby exhibit varying degrees of disease.

If you do not contact the dentist in a timely manner, peri-implantitis leads to complete rejection of the implanted tooth. Sometimes a relapse occurs, requiring removal of the structure and long-term restorative treatment.

Prevention

To avoid the occurrence or recurrence of peri-implantitis, you should follow some rules:

observe proper hygiene requirements for caring for the oral cavity and implants;
Conduct regular examinations with a doctor - at least 2-3 times a year;
avoid injuries and stress on the prosthesis structure;
quit smoking and alcohol;
contact only highly professional specialists;
monitor your health (in case of chronic diseases).

Price

The cost of treating peri-implantitis directly depends on the degree of the disease. The more work included in the treatment, the higher the cost.

The minimum cost is around 15 thousand rubles. Treatment with a new implant and restoration of bone tissue will cost 25 thousand or more.

Thanks to the improvement of technologies and techniques used in dentistry, complications are becoming less common.

Peri-implantitis is a disease that requires professional intervention in the early stages. Therefore, the patient’s timely visit to the clinic not only guarantees a successful treatment process, but also saves money.

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Peri-implantitis is an inflammation of the tissues surrounding a dental implant, which is accompanied by progressive loss of bone tissue around the implant (Fig. 1-3). Peri-implantitis can occur immediately after implant installation, or during the process of osseointegration (engraftment to the bone), or after prosthetics.

But besides “peri-implantitis itself,” there is another type of inflammatory process around the implant, which is called “mucositis.” Mucositis differs from peri-implantitis in that inflammation occurs only in the soft tissues of the gums around the implant (without affecting the bone). Accordingly, mucositis does not result in bone loss.

What peri-implantitis looks like: photo

This article is written for patients. In it we will dwell in more detail on the causes of peri-implantitis, as well as what urgently needs to be done in such a situation. For colleagues, at the end of the article there are a couple of links to English-language clinical studies on peri-implantitis.

Mucositis and peri-implantitis: symptoms

The development of mucositis and peri-implantitis is associated with an infectious process. Microbiological studies have shown that they are most often caused by pathogenic microorganisms such as spirochetes and gram-negative anaerobes. In particular, these include: Treponema denticola, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Bacterioides forsythus, Fusobacterium nucleatum.

Establishing diagnosis –
The diagnosis is made on the basis of an external examination, probing of the gum pocket, as well as X-ray data. With mucositis, swelling, redness or bluishness of the gums around the implant is observed, and bleeding occurs when probing the gum pocket. In this case, there are no signs of bone loss on x-rays.

If peri-implantitis has developed, the symptoms (in addition to swelling, redness or cyanosis of the gums, bleeding when probing the gums - characteristic of mucositis) will also include...

discharge of purulent or serous exudate from the gingival pocket and/or fistula,
probing depth of the gingival pocket is at least 5-6 mm,
X-rays will show bone loss around the implant.

Photo of a patient with peri-implantitis of the lateral incisor of the HF –

Important : According to various authors, the normal level of bone loss around the implant is considered to be a bone loss of 1.0-1.5 mm (during the 1st year), and then no more than 0.2 mm per year for all subsequent years. Any amount of bone tissue resorption above these indicators is considered pathological.

Peri-implantitis: treatment

Treatment of peri-implantitis is carried out only if the implant is immobile. If the mobility of the implant is determined, only its removal is indicated. Also, before starting treatment, it is important to assess the presence of increased chewing load on the implant, and if it exists, first of all it is necessary to neutralize it.

In addition, if a purulent abscess has formed in the implant area, then emergency opening of the abscess + systemic antibacterial therapy is necessary. To treat mucositis, only conservative methods are generally used (such as mechanical and antiseptic treatment of implants, antibacterial therapy), and surgical intervention may only be required to increase the thickness of the gums or the width of the attached gum.

But for the treatment of peri-implantitis, the main method will be only surgical treatment aimed at removing granulations from under the gums, replanting a bone graft with the parallel use of a barrier membrane.

1. Treatment of the implant surface –

With peri-implantitis, bone tissue is destroyed, which leads to partial exposure of the root surface of the implant. Because Since the latter has high porosity, it is subject to rapid contamination by pathogenic microflora. At the first stage of treatment, it is very important to disinfect the surface of the implant, removing all microbial plaques from the surface, plus carry out an antiseptic treatment.

For mechanical treatment of the implant surface, the following can be used:

mechanical curettage,
erbium laser (video 1),
ultrasonic tip (video 2),
sandblasting (Air-Flow).

The disadvantage of cleaning the implant surface using curettage or ultrasonic tips with metal tips is the high risk of injury to the titanium oxide layer on the implant surface, which can cause corrosion of the implant and lead to a new development of peri-implantitis. Therefore, it is best to use an erbium laser if available.

Next, an antiseptic surface treatment is carried out with either 3% hydrogen peroxide or a 0.1% chlorhexidine solution. Immediately after treatment with these antiseptics, it is necessary to treat the surface of the implant with a gauze swab with saline solution.

2. Systemic antibacterial therapy –

In other articles, we have already said that the ideal option for preventing peri-implantitis is a microbiological analysis of the microflora of the oral cavity, as well as its sensitivity to various antibiotics - performed even before the surgical stage of implantation. If extremely pathogenic microflora is inoculated, systemic antibiotic therapy is carried out even before surgery, which sharply reduces the risk of developing inflammation around the implant.

However, if there is no need to take antibiotics before surgery, this analysis will allow you, in the event of peri-implantitis, to immediately prescribe the best antibiotic option that will specifically target specific pathogenic microorganisms in a given patient. Believe me, this is important, because... Cases of resistance to broad-spectrum antibiotics are common.

There are clinical cases when the microflora in peri-implantitis does not respond not just to Amoxicillin, but also to Rovamycin or Vilprofen (a group of macrolides), and even sometimes to Ceftriaxone (a group of cephalosporins). In this case, a preliminary study of the microflora will allow you to save patients from removal of implants or large-scale reconstructive surgeries.

3. Surgical treatment (NTR technique) –

If peri-implantitis occurs, the treatment is predominantly surgical, and all of the above preliminary points are only secondary and necessary (as preparation for surgery). Surgical treatment is aimed at removing inflammatory granulations that form at the site of resorbed bone, as well as increasing the level of bone tissue using guided tissue regeneration (GTR).

Only surgical access allows you to remove all inflammatory granulations from under the gums, as well as mechanically and antiseptically treat the surface of the implants in the bone pockets. Absolutely all clinical studies have shown that conservative therapy for peri-implantitis (without surgical intervention, aimed at removing granulations and allowing for total disinfection of the root surface of the implant) is absolutely ineffective.

Operation strategy –
During surgery, a mucoperiosteal flap (gum) is removed to expose the surface of the implant and visualize the bone defect around the implant. Next, using curettage, scaling, and an erbium laser, all inflammatory granulations are removed, and antimicrobial treatment of the surface of the implant and bone defect is carried out. In implantology, it is customary to divide bone defects into 4-wall, 3-wall, 2-wall, single-wall and slit-like (Fig. 6).

It should be noted that the more preserved bone walls around the implant, the greater the chance for bone restoration around the implant during bone grafting. Therefore, if the patient’s bone defect around the implant is slit-like, 4- or 3-walled, in these cases bone grafting using the technique of directed tissue regeneration is indicated (Fig. 7). But, if the bone defect is single- or double-walled, bone resection with apical displacement of the flap is indicated.

Clinical studies have shown that the most effective method of bone grafting for peri-implantitis is NTR, using an autogenous bone graft + barrier membrane. At the same time, NTR can be carried out not only simultaneously with the removal of granulations and treatment of the surface of the implants, but also 1-3 months after the removal of granulations. The latter is necessary in cases of severe inflammation and the risk of bone graft suppuration.

Surgical treatment of peri-implantitis: video 1-2
In video 1, an erbium laser is used to disinfect the surface of the implant, and in video 2, an ultrasonic tip is used. Further, in both cases, the GTR (directed tissue regeneration) technique is used...

4. Aesthetic surgery for peri-implantitis –

We have already said that the development of peri-implantitis can also be caused by small thickness of the gums, as well as a lack of width of the attached (keratinized) gums around the implant. Therefore, in some cases, in addition to surgery to increase the bone level, additional surgeries may be required for -

increasing the width of the attached gum,
increasing gum thickness,
lip frenuloplasty,
surgery to deepen the vestibule of the oral cavity.

Naturally, in a good way, all these interventions should be done before or during the implantation operation, and if peri-implantitis has already occurred, they should prevent new inflammation. Also, indications for aesthetic surgery of the gums around the implant are gum recession (exposing the neck of the implant), as well as the absence of interdental papillae.

Causes of development of peri-implantitis –

As you will see below, in the vast majority of cases, the occurrence of peri-implantitis is not something unexpected or occurs by chance. On the contrary, its appearance is always natural, because In more than 90% of cases, it occurs as a result of errors by doctors (implant surgeon, orthopedic dentist, dental technician). These errors may be due to –

insufficient examination of the patient,
poor preparation of the patient's oral cavity for surgery,
errors when planning implantation,
non-compliance by the implantologist with the surgical protocol of the operation,
errors in prosthetics.

1. Main mistakes when preparing the patient –

If implantation is carried out at the site of a tooth that was removed due to inflammation (periodontitis), peri-implantitis may occur as a result of the fact that the doctor did not scrape out inflammatory granulations from the socket well enough when removing the tooth.
If implantation is performed in a patient who has a chronic infection of the nose, tonsils, (sinusitis), as well as sources of infection associated with poorly treated teeth. In this case, the patient will have quite aggressive pathogenic microflora in the oral cavity.
If during implantation in patients with periodontitis, periodontal pockets have not been sanitized, as well as antibiotic therapy (preferably after a preliminary microbiological analysis of the microflora).
If the doctor ignored the presence of systemic concomitant diseases in the patient, for example, diabetes mellitus, during implantation in women, he did not take into account the peculiarities of fluctuations in their hormonal levels, or the fact that the patient is an active smoker. Read more about the features of implantation in such categories of patients in the articles -

2. Main mistakes when planning an operation –

When planning the number and location of implant installation, it is very important to pay attention to the distances at which the implants will be installed from each other, as well as from neighboring teeth. It is also very important at the planning stage to determine the need for operations to increase the thickness of the gums and the volume of attached gums in the area of future implants. The development of peri-implantitis can result from:

The distance between the implant and the adjacent tooth is too small (less than 2.0 mm).
The distance between adjacent implants is too small (less than 3.0 mm).
Too small thickness of the gum (less than 2 mm) will not only not allow the formation of good aesthetics of the gum around the implant, but is also a poor barrier against the penetration of infection from the oral cavity into the osseointegration zone.
Too little attached gum around the implant (less than 4 mm) - over time, this will lead to the moving gum tearing off the “gingival cuff” around the implant. And the development of peri-implantitis is only a matter of time.

Optimal bone thickness and what attached gums look like: photo

3. Failure to comply with surgical protocol –

Most often, the development of peri-implantitis is associated with non-compliance with the surgical protocol for implant installation by an implant surgeon. The following errors may be made during the operation stage...

Titanium implants have an oxide layer on their surface that protects them from corrosion. In the event of accidental mechanical damage to the surface of the implant (for example, the doctor dropped the implant), the oxide layer is disrupted, which will first lead to corrosion of the implant, and later to the development of peri-implantitis.
Peri-implantitis can occur if bacterial contamination of the implant surface occurs before it is inserted into the bone. For example, when removing an implant from its packaging, a physician may accidentally place or drop the implant on a non-sterile surface. Also, when inserting an implant into the mouth, the doctor may accidentally touch it to the lip or mucous membrane of the oral cavity. And this will be enough for the development of inflammation.
If the doctor, when preparing the bone bed, handles the cutters with gloves containing talc. Particles of the latter will remain in the bone bed even after it is washed with an antiseptic and will certainly cause aseptic inflammation. Therefore, it is so important to use sterile surgical gloves without talc, or carefully remove talc from gloves using a 70 g swab. alcohol.
Inflammation can hardly be avoided if saliva gets into the finally formed bone bed under the implant. Not only does bacterial contamination occur here, but since saliva is very chemically aggressive, a superficial chemical burn of the bone occurs. The latter will interfere with osseointegration.
Normally, the diameter of the bone bed for the implant should be 0.5 mm less than the diameter of the implant. If the doctor has formed a bone bed for the implant that is too narrow, then the implant, after inserting it into the bone, will put too much pressure on the bone walls, which can provoke the development of inflammation.
If the doctor has formed a bone bed that is too wide compared to the diameter of the implant, this is also bad. This will not only result in poor primary stability of the implant, but also allow pathogenic bacteria to easily migrate along the surface of the implant.
Poor water cooling during the formation of the bone bed leads to bone burns and the development of peri-implantitis.
Inflammation will certainly occur if the cover screw or gum former is not tightly screwed into the implant. The infection will multiply in the existing gaps.
Incorrect placement of sutures when suturing the mucous membrane over the implant can also lead to bacterial contamination of the osseointegration zone and the development of inflammation.

4. Errors during prosthetics –

In addition to the mistakes made by the implant surgeon, there are a number of mistakes that the orthopedic dentist and dental technician can make at the stage of manufacturing the orthopedic structure. Peri-implantitis can result from:

excessive chewing load on the implant, which can occur, for example, due to an incorrect ratio of the height of the crown and the length of the root part of the implant, or if the width of the crown significantly exceeds the diameter of the implant;
if an abutment made of CCS (cobalt-chromium alloy) is installed in a titanium implant, this can lead to corrosion and the development of inflammation;
if there is a loose connection between the implant and the abutment, or the abutment and the crown (in this case, infection will multiply in the micro-gaps);
if the crown was fixed to the implant by cement fixation, excess cement could remain under the gum, which would cause inevitable inflammation;
if the flushing space under the bridge prosthesis on implants is incorrectly created;
if the angle between the axis of the crown and the axis of the implant is more than 27 degrees,
etc…

5. Patient related factors –

The patient’s objective guilt in the development of peri-implantitis concerns only poor oral hygiene, as well as smoking. Both of these factors greatly increase the risk of developing peri-implantitis. However, there are a number of other conditions and underlying diseases that can also increase the risk of developing inflammation around implants.

bruxism (teeth grinding),
long-term treatment with corticosteroids,
previously completed chemotherapy,
concomitant systemic diseases, for example, diabetes mellitus or osteoporosis, increase the risk of developing peri-implantitis (but are not independent factors in its occurrence).

Important : These conditions and diseases are not an absolute contraindication to implantation, but the doctor, when deciding to undergo implantation, must carefully weigh the pros and cons, warning the patient about the increased risk of complications. Very often, doctors, in pursuit of earnings, accept implantation on patients with extremely unfavorable health status, and the patients then pay for this with the natural development of complications. We hope that our article was useful to you!

Sources:

1. Add. professional,
2. Personal experience of a dental surgeon (implantologist),
3. The National Center for Biotechnology Information (USA),
4. “Complications during dental implantation” (A.V. Vasiliev),
5. " Professional hygiene in the field of implants and treatment of peri-implantitis "(Susan S. Wingrove).