Dental implants are currently one of the safest alternatives for replacing missing teeth, regardless of their cause. This treatment has shown a high degree of predictability, with a survival rate in the range of 90–95% for more than 5 years [1]. The incidence of technical and biological complications appears to be common [2–4], and these complications can have substantial economic implications and effects on patient perception of treatment.
Among biological complications, peri-implant diseases are considered the most relevant. They have an infectious cause and two entities have been described: mucositis and peri-implantitis [5]. Peri-implantitis is characterized by a destructive inflammatory lesion of polymicrobial etiology that affects both soft and hard tissues, leading to progressive peri-implant bone loss, along with pocket formation and inflammation in the peri-implant tissues [6]. Therefore, the pathognomonic clinical sign of peri-implantitis will be the increase in pocket depth accompanied by bleeding and often suppuration [7].The therapeutic approach to resolving this complication is neither univocal nor well-defined in the international scientific literature. Depending on the clinical case and the stage at which they are identified, treatment can be surgical or non-surgical. In both approaches, we use substances capable of completely or almost completely “disinfecting” the implant surface, which is highly susceptible to bacterial flora due to its rough macro- and micro-geometry. Therefore, leveraging the antibacterial, antiviral, and fungicidal properties of ozone, combined with a heterologous connective tissue graft to increase the amount of keratinized mucosa, can be crucial in both the clinical and radiographic resolution of this implant pathology.
Fig.1
Spontaneous bleeding from the implant in position 36. Suspected peri-implantitis.
Fig.2
Radiographic image confirming the diagnostic doubt with extensive peri-implant bone resorption involving approximately half of the fixture.
Fig.3
Once the crown is removed, and a full thickness flap raised, a large amount of granulation tissue is observed surrounding the implant in position 36.
Fig.4
Once the inflammatory tissue was removed, the surface was decontaminated using manual, rotating titanium and ultrasonic instruments.
Fig.5
After mechanical cleaning, chemical cleaning of the implant surface is performed using a highly concentrated ozone-based gel, kept in place for 5 minutes and then eliminated by washing with physiological solution.
Fig.6
The defect around the implant was filled with thermal-treated equine bone and the surgical screw is positioned to re-submerge the implant.
Fig.7
An heterologuos connective tissue graft was positioned over the implant and the bone graft in order to augment the quantity and quality of the keratinazed tissue.
Fig.8
Final suture with monoamyd 5/0 row in order to obtain a primary wound closure.
Fig.9
Wound healing after 15 days.
Fig.10
After 6 months, the reopening procedure is performed, with a great amount of keratinized tissue.
Fig.11
New monolithic zirconia crown screwed onto the implant: the soft tissues appear in excellent condition.
Fig.12
Final xray more than 6 months after the surgery: the equine graft seems to be completely integrated in the sorrounding bone and in contact with the re-osseointegrated implant.
Fig.13
Clinical situation 4 years later.
Fig.14
Xray follow up after 4 years with a complete bone healing.
Conclusions
The treatment of peri-implant infections is always complex and difficult to resolve. For this reason, the most important aspect is cleansing the contaminated implant surface. To achieve this, every tool in our arsenal must be employed, from mechanical to chemical instruments, and the use of highly concentrated ozone appears particularly useful in this regard.
Once the best possible cleansing has been achieved, it is necessary to reconstruct the soft and hard tissue surrounding the treated implant. Indeed, the ability to recreate an adequate quantity and thickness of keratinized mucosa around the healed implant appears to be of fundamental importance in maintaining the results obtained.
Bibliography
- Berglundh T, Persson LG, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2008;3:197–212.
- Zitzmann NU, Berglundh T. Definition and Prevalence of peri-implant diseases. J Clin Periodontol. 2008;35(8):286–291.
- Albrektsson T, Donos N. Implant survival and complications. The third EAO consensus conference 2012. Clin Oral Implants Res. 2012;23(6):63–65.
- Pjetursson BE, Karoussis I, Burgin W, Bragger U, Lang NP. Patients’ satisfaction following implant therapy. A 10-year prospective cohort study. Clin Oral Implants Res. 2005;16:185–193.
- Lindhe J, Meyle J. Group of European Workshop on Periodontology. Peri-implant diseases: consensus of the sixth European Workshop on Periodontology. J Clin Periodontol. 2008;35:282–285.
- Charalampakis G, Rabe P, Leonhardt A, Dahlén G. A follow-up study of peri-implantitis cases after treatment. J Clin Periodontol. 2011;38:864–871.
- Derks J, Schaller D, Hakansson J, Wennstrom JL, Tomasi C, Berglundh T. Peri-implantitis-onset and patter of progression. J Clin Periodontol. 2016;43:383–388.
