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IMPLANT FUNDAMENTALS PART 3: IMPLANT MAINTENANCE & REPLACEMENT

A Peer Reviewed Publication by Hu-Friedy

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Dr. Jon Suzuki

Professor, Department Chair, Program Director – Periodontology & Oral Implantology DepartmentTemple University Kornberg School of Dentistry

Prof. Mauro Labanca

Private practice, Milan, Italy Consulting Professor of Anatomy, University of Brescia.

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SOLUTIONS OVERVIEWIMPLANT FUNDAMENTALS

Dr. Carlos Quinones

Associate Professor, Department of Surgical Sciences, Division of Periodontics, University of Puerto Rico School of Dental Medicine Private practice, San Juan, Puerto Rico.

Dr. Lee Silverstein

Associate Clinical Professor of Periodontics at the Georgia Health Sciences University, College of Dental MedicineKennestone PeriodonticsMarietta, GA

SCIENTIFIC REVIEWERS

Dr. István Urbán

Associate Professor, Department of Periodontology, University of Szeged, HungaryPrivate practice, Budapest, Hungary

© 2016 by Hu-Friedy Mfg. Co., LLC

First EditionAll 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.

Hu-Friedy Mfg. Co., LLC is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by the AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 6/1/2015 to 5/31/2019. Provider ID# 218966.

Managing Peri-Implantitispage 10

Patient Assessmentpage 5

ABSTRACTIn 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.

OBJECTIVESAt 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.

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.

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.

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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.

PHYSIOPATHOLOGYDental implants, as foreign bodies inserted into alveolar bone, may carry with them the complications of a foreign body reaction. Dental implants are made of biologically inert metal (usually titanium). When inserted in the alveolar ridge, they are not supported by connective tissues or junctional epithelium in the 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.

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 for infection to occur as a result of either neglecting or 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 5.1 Diagram of the mucosal barrier that exists around a dental implant.

Figure 5.2 Clinical depiction of peri-implant mucositis.

Figure 5.3 Elevation of surgical flap reveals bone loss consistent with peri-implantitis.

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PATIENT ASSESSMENTImplant 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 with active or previous periodontitis pose a higher risk of 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 unfilled resin instruments as they are less likely to abrade or roughen the surface of the 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 5.4 Probing serves a valuable role in assessing hard tissue changes at the implant site over time.

Figure 5.5 Radiograph demonstrates an implant with a healing abutment in place.

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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DIAGNOSISOn 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.

The frequency of professional treatment for implant maintenance is 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 with glycine powder has also been effective around implants, 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 professional.

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 glycine 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 considering hand instruments, unfilled resin, titanium or carbon fiber materials are available, with unfilled resin least affecting the titanium surface.

Figure 5.8 Plaque is removed with a gentle touch and gradually expanding circumferential strokes.

Figure 5.9 Scaling is performed using oblique, circular, and parallel strokes. Polishing of the implant may be necessary if its surface appears roughened.

Figure 5.7 Side-by-side comparison of healthy vs. unhealthy peri-implant tissues.

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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 EDUCATIONHome 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 early for treatment. Meticulous oral hygiene including brushing and flossing are encouraged, since pathogenic bacteria from anywhere in the mouth will more aggressively attack these healing tissues. An ADA Council of Scientific Affairs accepted antimicrobial mouthrinse is often part of the recommended home 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.

CONCLUSIONSWhile 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.

Perform Scaling Without Altering Abutment Surfaces

Keep implant components smooth and prevent surface alterations that can create an environment prone to plaque entrapment and bacterial buildup

• Reduce the potential for peri-implant mucositis or peri-implantitis

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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.

REFERENCES

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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 succes — 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 FAILUREA number of patient-related factors influence implant survival, including his/her overall health, smoking habits, and compliance with oral hygiene instruction. Uncontrolled diabetes, chemotherapy, and the patient’s failure to wear a night guard also 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 implant placement, causes of failure have been attributed to peri-implantitis (Figure 6.1), occlusal trauma (Figure 6.2),

Figure 6.1 Radiograph of bacterial plaque-induced destruction of the peri-implant tissues.

Figure 6.2 Histological view of peri-implant tissue destruction, attributed to occlusal trauma, that requires surgical intervention and occlusal control.

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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 OsseointegrateWhen 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 may require a delayed surgical approach.

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 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-ImplantitisWhen 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 condition around dental implants and is often 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.

Figure 6.5 Clinical outcome of peri-implantitis addressed via guided bone regeneration, i.e., surgical approach.

Figure 6.4 Guided tissue regeneration performed at site of implant failure.

Figure 6.3 Implant failure that requires surgical intervention.

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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-abrasive devices (AADs) 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 abrasive 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).

Use Non-Metal Instruments as a Best Practice for Debridement

Complete removal of accretions and excess cement should be performed with plastic (unfilled resin) instruments to prevent alteration of implant and abutment surfaces

• Set appropriate recall visits based on the patient’s needs and risk of disease

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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. Combine 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 uncontaminated and still capable of biological healing (Misch 2014).

In his 2015 text Dental Implant Prosthetics, Misch outlined specific criteria that constituted clinical failure and would require implant removal (Table 6.1). According to Misch, these implant sites, as well as those where implants were surgically removed or exfoliated, can be grafted 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.

CONCLUSIONSThe 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.

TABLE 6.1 CRITERIA FOR IMPLANT REMOVAL

Pain upon palpation, percussion, or function

Horizontal mobility over 0.5mm

Vertical mobility of any kind

Progressive bone loss that cannot be controlled

Uncontrolled exudate

More than 50% bone loss around the implant

Generalized radiolucency

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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.

REFERENCES

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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.

REFERENCES