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The term peri-implantitis is used to describe a destructive inflammatory process affecting the soft and hard tissues around osseo integrated implants, leads to the formation of a peri-implant pocket and loss of supporting bone. Predisposing factors are Poor Plaque Control, inflammation, infection, Smoking, Diabetes and Occlusal Overload. It is diagnosed on the basis of clinical and radiographic interpretation and still no definite criteria have been proposed for the diagnosis and treatment of peri-implantitis. However treatment can be both conservative and surgical. The cumulative interceptive supportive therapy protocol serves as good guide for the treatment of the peri-implantitis. There is lack of a standard classification system to differentiate the various degrees of peri-implantitis, which produces dilemma in evaluating the stages clinical and radiological status, treatment and its outcome. Many classification has been proposed in medical literature with their pros and cons but still there is lack of standard classification system of implant defects and definite treatment protocol according to the same. The classification should be easy to use, clearly understandable and help in communication by clinicians of different speciality. This review aimed to introduce a classification system based on added clinical, and detailed radiological parameters with prognosis and staged treatment algorithms.
The dental implants are the one of the greatest revolution in the restoration of the patient’s function, esthetics and long-term survival for partially/fully edentulous conditions in dentistry. Inspite of their high predictibilty and success rates, biological complications do occurs. The term peri-implant mucositis and peri-implantitis which affects the dental implants are analogous to the terms gingivitis and periodontitis which affects the periodontium of natural teeth. Peri-implant mucositis is a disease in which the presence of inflammation of soft tissues surrounding a dental implant, without the signs of supporting bone loss following initial bone remodeling during healing where as Peri-implantitis is an inflammatory phenomenon, including soft tissue inflammation and progressive loss of supporting bone around an implant. These definitions are worldwide accepted, but still there is dilemma regarding diagnostic criteria. The diagnosis can be made simultaneously clinically and radiologically. The signs and symptom of peri-implantitis includes typical saucer shaped destruction of the crestal bone vertically as radiologic finding and osseointegration of the apical part of the fixture. Formation of a peri-implant pocket. Bleeding with or without suppuration on gentle probing (<0.25 N). Mucosal swelling and hyperplasia. Generally asymptomatic but pain can be associated with an acute infection. An average of crestal bone loss of 0.9–1.6 mm is noted during the first post-surgical year and then a yearly loss of 0.02–0.15 mm is observed.1 Treatment of peri-implantitis, can be both conservative as well as surgical therapies. Conservative therapy includes medication and manual treatment with curettes, ultrasonic and air polishing systems, advance techniques such as laser-supported and photodynamic therapy. The surgical treatments methods are resective or regenerative procedures with bone grafting and flap surgery.
Mombelli developed the Cumulative Interceptive Supportive Therapy (CIST) protocol for maintenance of the dental implant and management of peri-implantitis. Parameters like infection, bleeding, suppuration (pus), pocket depth on probing, radiolucency on X-ray are considered into the protocol.2Treatment modalities for treatment of peri-implantitis includes Initially debridement, irrigation of pocket with disinfectant and supplimenting antibiotic cover to reduce any active inflammation. Chlorhexidine 0.2% is very much effective in the reduction of pocket depths, increased tissue implant adhesion and general reduction of inflammation. Systemic and local antibiotic applications with Amoxicillin, Metronidazole, Doxycycline, Tetracycline, Minoxicycline hydrochloride, Ciprofloxacin can significantly reduced pocket depths. Detoxification procedures to decontaminate affected implant surfaces are air-powder abrasion, saline wash, citric-acid application and peroxide treatment, Photodynamic therapy using the Er:YAG, Helbo laser for decontaminating the implant and bone both. Reflection of the full thickness mucoperiosteal flap up to the edge of the intact bone followed by Surgical curettage of all granulation tissue and cleaning of the titanium surface with plastic curette and a titanium brush. Regenerative treatment using autogenous bone graft to stabilize the soft tissue and to prevent the formation of new pockets. Advanced novel therapy includes De-epithelisation of the pocket with the diode laser.
There are numbers of classification of peri-implant defects quoted in medical literature but still there is lack of standard classification system of implant defects highlighting degrees of peri-implantitis, clinical and radiological condition, treatment, outcome and prognosis. The review highlights various classifications for dental peri implant defects or periimplantitis and an attempt is made to propose a classification of implant defects.
Branemark in 1952 described titanium as a biocompatible material that “fuses” to bone and till date titanium is the gold standard material for of implants globally. Osseointegrated dental implants are predictable treatment option for replacement of missing teeth, around the world. Success rates of more than 90% and predictability of dental implants is well published in literature, but still complications and failures occurs. There are number of classifications of periimplant defects quoted in medical literature with their Pros and cons but till date there is no uniformly accepted classification. Various system of classification proposed in literature described below.
Schwarz et al.3 classified peri implant defect depending on the configuration of the bony defect as:
Class I defect – Intraosseous
Class II defect – Supra-alveolar in the crestal implant insertion area.
This Classification informs about only two classes. No clinical and radiological interpretation is evident.
Spiekermann4 characterized peri-implant defect into the type of bone resorption pattern into 5 category.
Class I – Horizontal,
Class II – Hey-shaped
Class III a – Funnel shaped
Class III b – Gap-like
Class IV – Horizontal-circular form
This classification describes 5 different patterns of bone resoption around implant. No clinical criteria and treatment protocol for each class is given in it.
Another system of classification exists amount of bone loss with shaped of defect associated5
Class 1: Slight horizontal bone loss with minimal peri-implant defects
Class 2: Moderate horizontal bone loss with isolated vertical defects
Class 3: Moderate to advanced horizontal bone loss with broad, circular bony defects.
Class 4: Advanced horizontal bone loss with broad, circumferential vertical defects, as well as loss of the oral and/or vestibular bony wall
This classification reveals horizontal bony defect along with other types of bony defects around implant. No clinical picture, treatment modality and prognosis is highlited.
A new classification of bone defects adjacent to dental implants highlighting the defect anatomy in the progression of the regenerative process6
The classification could be a useful tool for planning the correct regenerative procedure for each type of defect but classification lacks clinical and radiological assessment statistically.
Peri-implantitis is classified into7:
PD ≥ 4 mm, Bleeding and/or suppuration on probing, Bone loss <25% of the implant length.
PD ≥ 6 mm, Bleeding and/or suppuration on probing, Bone loss ranging from 25% to 50% of the implant length.
PD ≥ 8 mm, Bleeding and/or suppuration on probing, Bone loss >50% of the implant length.
(Atleast two aspect of implant with evidence of Bleeding and/or suppuration. Bone loss was measured on most recently radiograph taken and compare with radiograph taken at the time of prothetic loading).
This classification provides a standarised method about clinical and radiographic status of implant but it does not share any information of information related to management of periimplantitis and prognosis.
Combined Classification of peri-implant mucositis and peri-implantitis8
This is combined (peri-implant mucositis and peri-implantitis) classification giving valuable information for clinical status of implant. However lacks prognosis and treatment criteria.
Lang NP etal classification included treatment part in its classification.9
This is a good classification which provides clinical radiological information and therapeutic part but still insufficient detail about type of bony defect and prognosis.
Zhang L etal demostrated classification of peri-implant bone defects (PIBDs) on the basis of their Panoramic radiographic shapes in patients with lower implant-supported overdentures. They are broadly classifieds into decreasing orderr of occurrence.10
This classification is given for lower implant-supported overdentures cases only and focus on different shapes ans patterens of bony defects exclusively. Lacks clinical and detailed radiographic interpretations.
A clinically symptomatic periapical lesion that develops with in the first few after implant insertion while the coronal portion of the implant sustains a normal bone to the implant interface.11
Class I – Mild – Extends < 25% of the implant length fron implant apex.
Class II – Moderate – Extends 25–50% of the implant length fron implant apex.
Class III – Severe – >50% of the implant length fron implant apex.
It is a good classification of retrograde implantitis. None of the classifications described have mentioned any point about this.
Passi D (2016): Newer Proposed Classification
APF- Apically positioned flap, GBR- Guided bone regeneration, ABWG- Autogenous bone wedge grafting.
This classification uses menomics B (Bleeding,Bone loss), M (Mobility), P (Probing depth,Proposed treatment and Prognosis). Hence the name BMP classification of implant defects is given. This classification describes clinical parameters and soft tissue conditions like bleeding on probing, extent of probing depth and mobility of implant .It includes radiographic parameters like Bone loss (in percentage) of implant length and type/orientation of implant defect. It also includes stage wise management of defect and its prognosis. The main limitation of the classification that it lacks to include any etiological factors like bacterial or trauma and is bit complex and lenghty to read. Also this classification doesnot includes any relations of implant to adjacent natural teeth.
The proposed classification allows both clinical and radiographic interpretation of implant defects and can serves as easy, reproducible and good guideline for treatment planning and prognosis.