Dental implants are a hugely successful solution for restoring aesthetics and function to edentulous patients. Although the procedure is increasingly successful, failures do still occur, and a number of factors can be to blame, including the health and age of the patient, habits like smoking or poor dental hygiene, the quality of bone and soft tissue, or systemic disease, often in combination.[i] The leading cause of implant failure, however, is avoidable infection.[ii]
As soon as an implant surface is exposed to the oral cavity, it becomes colonised by oral microorganisms, forming a microbial biofilm. Conventional treatment for managing peri-implant diseases has in the past tended to disregard the contributory characteristics of dental implant design and materials, following evidence available for the treatment of periodontitis. However, the design of the implants, combined with various surface modifications of titanium, may foster increased plaque accumulation, resulting in faster bacterial biofilm formation than on natural teeth.[iii]
Microorganisms most commonly associated with implant failure are spirochetes and mobile forms of Gram-negative anaerobes. Diagnosis is based on colour and appearance-changes in the gingiva, bleeding and probing depth of peri-implant pockets, suppuration, radiographic evidence of bone-resorption, as well as the degree and extent of gradual loss of bone height around the tooth.[iv]
Peri-implantitis, the plaque-associated, site-specific infection, is characterised by inflammation in the peri-implant mucosa and consequent gradual bone loss. The condition is a progressive and largely irreversible disease of the hard and soft tissues surrounding the implant and is accompanied with bone resorption, decreased osseointegration, increased pocket formation and the presence of purulence.[v]
Non-surgical management of peri-implant disease
In some cases, with the correct management, it is possible to regain osseointegration non-surgically. For non-surgical treatment to be effective, early detection and accurate diagnosis makes all the difference. The prosthetic itself should be checked for any ill-fitting components or design flaws that impede oral hygiene. Effective plaque control by the patient is paramount for implant success. If inflammation persists regardless of low plaque scores, further investigations addressing the patient’s general health may be warranted, and the prosthetic might need to be modified or replaced.[vi]
Once any contributing factors have been eliminated, like poor oral hygiene, smoking, or mechanical problems with the implant, the first priority is to control the infection.[vii]
Mechanical debridement can effectively reduce bleeding on probing (BOP) by 20%–50%. In cases of mild peri-implant disease, debridement by air-polishing devices, YAG lasers, or curettes can reduce pockets by around 1mm.[viii]
The addition of antiseptic therapy to mechanical debridement has not been proven to provide additional benefits where the pocket depth is less than 4mm but may help with deeper peri-implant lesions.[ix] The addition of systemic antibiotics can also improve outcomes.[x]
Surgical techniques for peri-implantitis
In conventional surgical management of peri-implantitis, the damaged implant is thoroughly debrided and decontaminated with the use of a surgical flap. Surgery often involves using autogenous bone grafts, with a control access flap procedure.[xi]
Resective surgery has been shown to be effective in reducing symptoms of peri-implantitis. This entails using ostectomy and osteoplasty techniques combined with bacterial decontamination. Outcomes are improved by combing resective therapy with implantoplasty – a process of smoothing and polishing the supracrestal implant surface.[xii]
Studies have indicated that combining resective therapy with bone grafting procedures can provide a significant improvement to peri-implant health for about 6 months to 2 years after surgery. However, over time, bone-loss can still occur.[xiii]
Soft tissue grafting to manage peri-implantitis
Soft tissue grafting is not a new procedure. Invented 50 years ago, it has been increasingly used in clinical practice for augmenting tissue thickness, re-establishing an adequate width of keratinised tissue, correcting mucogingival deformities, and improving aesthetics, around teeth and dental implants.[xiv]
An increasing number of studies suggest that soft tissue grafting techniques might be more effective than bone grafts in successfully preventing and treating peri-implant diseases, reducing marginal bone loss, biofilm accumulation and peri-implant inflammation.[xv] The use of an autogenous connective tissue graft (CTG) can be an effective treatment for peri-implantitis when there is gingival recession and a lack of keratinised mucosa, associated with increased plaque accumulation and attachment loss.[xvi]
Learn directly with the innovators
World-renowned periodontologist, Professor G. Zucchelli, has published widely on soft tissue management around teeth and implants. He leads an advanced course on the subject at the Academy of Soft and Hard Tissue Augmentation (ASHA) this autumn, alongside highly respected clinician in the field, Dr Selvaraj Balaji. This one-of-a-kind, 2-part course – entitled Soft Tissue Management Around Teeth & Implants – combines theory and practice to equip participants with the newest research, unique techniques and exciting innovations to manage soft tissue around teeth and implants.
Infection can threaten the survival of implants at any point after their placement. When preventative measures and non-surgical therapies have not been effective, surgical intervention is the only option. By maintaining proficiency in the most advanced techniques and theory in the field, clinicians can offer their edentulous patients more support, and more options, leading to happier and healthier outcomes.
Find out more at https://www.ashaclub.co.uk/courses
Soft Tissue Management Around Teeth & Implants
15th & 16th November 2024 / 10th & 11th January 2025
To book, please call: 07974 304269 or email: info@ashaclub.co.uk
Author: Dr Selvaraj Balaji
Dr Balaji since he obtained the BDS Degree, he worked in Maxillo facial units in the UK for several years and gained substantial experience in surgical dentistry.
For the past 15 years Dr Balaji has been working in his private dental practice which is based in Buckingham. He is the principal dentist and owner of The Gallery Dental Group which is made up of Meadow Walk Dental Practice and The Gallery Dental & Implant Centre.
He is the founder of the Academy of Soft and Hard Tissue Augmentation (ASHA) and run courses and lectures in the UK and around Europe, where he teaches other aspiring implantologists how to treat difficult cases. In addition, He also hosts study clubs, webinars.
[i] Kochar SP, Reche A, Paul P. The Etiology and Management of Dental Implant Failure: A Review. Cureus. 2022 Oct 19;14(10):e30455. doi: 10.7759/cureus.30455. PMID: 36415394; PMCID: PMC9674049.
[ii] Kochar SP, Reche A, Paul P. The Etiology and Management of Dental Implant Failure: A Review. Cureus. 2022 Oct 19;14(10):e30455. doi: 10.7759/cureus.30455. PMID: 36415394; PMCID: PMC9674049.
[iii] Prathapachandran J, Suresh N. Management of peri-implantitis. Dent Res J (Isfahan). 2012 Sep;9(5):516-21. doi: 10.4103/1735-3327.104867. PMID: 23559913; PMCID: PMC3612185.
[iv] Prathapachandran J, Suresh N. Management of peri-implantitis. Dent Res J (Isfahan). 2012 Sep;9(5):516-21. doi: 10.4103/1735-3327.104867. PMID: 23559913; PMCID: PMC3612185.
[v] Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis–a review. Head Face Med. 2014 Sep 3;10:34. doi: 10.1186/1746-160X-10-34. PMID: 25185675; PMCID: PMC4164121.
[vi] Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL; Working Group 3. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants – Consensus report of working group 3. Int Dent J. 2019 Sep;69(Suppl 2):12-17. doi: 10.1111/idj.12490. PMID: 31478575; PMCID: PMC9379037.
[vii] Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL; Working Group 3. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants – Consensus report of working group 3. Int Dent J. 2019 Sep;69(Suppl 2):12-17. doi: 10.1111/idj.12490. PMID: 31478575; PMCID: PMC9379037.
[viii] Renvert S, Hirooka H, Polyzois I, Kelekis-Cholakis A, Wang HL; Working Group 3. Diagnosis and non-surgical treatment of peri-implant diseases and maintenance care of patients with dental implants – Consensus report of working group 3. Int Dent J. 2019 Sep;69(Suppl 2):12-17. doi: 10.1111/idj.12490. PMID: 31478575; PMCID: PMC9379037.
[ix] Kochar SP, Reche A, Paul P. The Etiology and Management of Dental Implant Failure: A Review. Cureus. 2022 Oct 19;14(10):e30455. doi: 10.7759/cureus.30455. PMID: 36415394; PMCID: PMC9674049.
[x] Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis–a review. Head Face Med. 2014 Sep 3;10:34. doi: 10.1186/1746-160X-10-34. PMID: 25185675; PMCID: PMC4164121.
[xi] Kochar SP, Reche A, Paul P. The Etiology and Management of Dental Implant Failure: A Review. Cureus. 2022 Oct 19;14(10):e30455. doi: 10.7759/cureus.30455. PMID: 36415394; PMCID: PMC9674049.
[xii] Smeets R, Henningsen A, Jung O, Heiland M, Hammächer C, Stein JM. Definition, etiology, prevention and treatment of peri-implantitis–a review. Head Face Med. 2014 Sep 3;10:34. doi: 10.1186/1746-160X-10-34. PMID: 25185675; PMCID: PMC4164121.
[xiii] Schwarz F, Jepsen S, Obreja K, Galarraga-Vinueza ME, Ramanauskaite A. Surgical therapy of peri-implantitis. Periodontol 2000. 2000; 88(1): 145-181.
[xiv] Zucchelli G, Tavelli L, McGuire MK, Rasperini G, Feinberg S E, Wang HL, Giannobile WV. Autogenous Soft tissue Grafting for Periodontal and Peri-implant Plastic Surgical Reconstruction. Department of Periodontics and Oral Medicine; University of Michigan, School of Dentistry. Ann Arbor MI. August 2019. doi: 10.1002/JPER.19-0350.
[xv] Galarraga-Vinueza ME, Tavelli L. Soft tissue features of peri-implant diseases and related treatment. Clin Implant Dent Relat Res. 2023 Aug;25(4):661-681. doi: 10.1111/cid.13156. Epub 2022 Nov 29. PMID: 36444772.
[xvi] Mahn, D.H. (2016), Use of an Autogenous Connective Tissue Graft to Treat Peri-Implantitis With Gingival Recession Affecting an Implant Supporting an Overdenture. Clinical Advances in Periodontics, 6: 161-165. https://doi.org/10.1902/cap.2016.150088
