One of the big challenges that confronts periodontists in tackling peri-implantitis is what to do when lesions develop around infected implants, especially if these are in the aesthetic zone.
While regenerative techniques can be applied in these situations, there is as yet no standard treatment, although there are several promising approaches.
This important topic is the subject of one of the sessions at the EFP’s Perio Master Clinic 2017 – Peri-implantitis: from aetiology to treatment, which takes place in Malta on March 3 and 4.
“Overall, there is a lack of comparative studies with low risk of bias, so no regenerative treatment has been proven to be superior,” says Ioannis Polyzois, moderator of the session Regeneration of peri-implantitis defects – is it possible? which takes place on Saturday, March 4. “Complications are common and are mainly due to membrane exposure".
He adds that non-surgical therapy should first be carried out to arrest the progression of the disease and reduce inflammation in the peri-implant pocket. Before deciding whether or not to opt for a regenerative approach or which regenerative technique to use, “a number of patient-related, implant-related, defect-related, and treatment-related factors have to be considered.”
Radiographic and clinical examinations can provide some information on the morphology of the bony defect but do not give a complete picture. “As the defect configuration is of great importance to the clinical outcome, elevation of a flap and removal of granulation tissue is a necessary step in identifying this configuration,” says Dr Polyzois, director of the postgraduate course in periodontics at Trinity College Dublin (Ireland).
Another factor that is crucial to the success of regenerative procedures is the implant-surface decontamination protocol because “recent evidence suggests that certain antimicrobial agents might compromise the biocompatibility of the titanium surface.”
The promise of L-PRF
One promising approach, which will be discussed in detail in this session of Perio Master Clinic 2017 by Marc Quirynen, head of periodontology and oral microbiology at the Catholic University of Leuven (Belgium), is the use of a living-tissue material for grafting: Leucocyte-Platelet Rich Fibrin (L-PRF), one of the four main families of platelet concentrates.
“Apart from its promising biological and mechanical properties, short-term antimicrobial effects have also been reported,” notes Dr Polyzois, although he cautions that there is not yet a standardised protocol for the production and use of L-PRF and “no available scientific evidence on its effectiveness on peri-implant defect regeneration.”
Also speaking in this session will be Mario Roccuzzo, lecturer in periodontology at the University of Turin (Italy), who will discuss regenerative surgical treatment of peri-implantitis using membranes and different bone-augmentation procedures.
“When peri-implantitis has already caused extensive bone resorption, the dentist faces the dilemma of when regenerative therapy is appropriate to maintain the implant or whether removal and replacement with a new implant should be preferred,” he says.
While there is not yet a surgical technique that is able to “predictably regain osseointegration,” there is a novel approach to hard-tissue reconstruction which Dr Roccuzzo will discuss during his presentation.
He adds that the four main challenges in regenerative surgical treatment of peri-implantitis are defect selection, patient preparation, surgical-flap management, and post-operative care. Participants in this session will learn how to identify peri-implantitis cases where regeneration is indicated, how to select the ideal regenerative surgical treatment, and how to establish a maintenance programme for long-term success.
In the second session on Saturday, March 4, participants in Perio Master Clinic 2017 will hear presentations about treatment plans for advanced cases of peri-implantitis.
In this session, moderated by Moshe Goldstein, chair of the EFP’s postgraduate education committee, Pascal Valentini (programme director for European postgraduate oral implantology at the University of Corsica) will address the question of what happens if the “man-made bone” gets infected.
Mauro Merli, a visting professor at the Università Politecnica della Marche in Ancona (Italy) and author of Implant Therapy: The Integrated Treatment Plan, will then explore the question of how to handle hard- and soft-tissue defects following the removal of an implant.
His presentation will evaluate surgical techniques for bone reconstruction in severely atrophic jaws where implant placement has been planned, and focus on the many complex aspects regarding soft-tissue handling in implant surgery. The decision-making process that leads to the potential extraction of the compromised implant will be outlined in detail.
“The objective of the clinician is to follow a procedure that reduces invasiveness and provides patient satisfaction in reaching the desired goals,” says Prof Merli, who highlights a new surgical procedure – the “fence technique” – where the volume of bone augmentation can be planned.
“This technique allows for the formation of large quantities of bone in both the horizontal and vertical dimension, with limited discomfort for the patient,” he said. “Space-making is obtained and maintained by osteosynthesis plaques and collagen membranes, to be filled with autologous bone alone or the combination of bone substitute and autologous bone.”
His presentation will also deal with the management of peri-implant soft tissue in terms of techniques applied before or during abutment connection,
“Peri-implant plastic surgery aims to correct and harmonise peri-implant supracrestal structures after abutment connection, using soft-tissue surgical techniques refined for periodontal applications, with the intention of providing not only aesthetic but also a biological benefit,” says Merli.
He will also offer a critical analysis of the most recent scientific literature regarding the various surgical procedures that are available, along with the results of clinical research compiled by a team of multidisciplinary professionals, to guide clinicians to make the most rational choice for each specific case.
Exciting scientific programme
These presentations are part of a high-level scientific programme at Perio Master Clinic 2017, put together by scientific chair Stefan Renvert.
There are still a few places available at this prestigious event which brings together many of Europe’s experts in the field of peri-implantitis to share the latest scientific knowledge and innovations in clinical practice. Registrations can be made and accommodation booked via the EFP website.
As Korkud Demirel, chair of the organising committee, puts it: “The aim of Perio Master Clinic meetings is to bring together clinicians with the desire to improve their skills in clinical practice to the highest levels of excellence.”