Frank Schwarz, Jürgen Becker
Peri-implant Infection: Etiology, diagnosis and treatment
With contributions from:
Akira AOKI, Martin SAGER, Katrin SCHWARZ,
Anton SCULEAN, Aristeo Atsushi TAKASAKI
Euro148,-/ $ 220/£128,17x24
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U4-Text
As more and more people today are choosing dental implants over traditional methods of
tooth replacement, a corresponding rise in the number of individuals with post-implant
complications can be expected. Consequently, the significance of treating conditions such as
peri-implant infections is mounting. This book provides a clear and easily comprehensible
description of peri-implant tissue anatomy and structure as well as of the etiological and
pathogenetic factors associated with peri-implantitis. Clinical features and current options for
diagnosis of peri-implant disease (including radiological and microbiological procedures) are
discussed in detail based on numerous case studies. Using a modular treatment approach
placing special emphasis on clinical relevance, this book provides a comprehensive and
critical introduction to non-surgical procedures, including laser therapy and implant surface
decontamination, antimicrobial and antiphlogistic treatments, and surgical procedures,
including resective and regenerative procedures as well as explantation.
CV
Frank Schwarz, PD Dr.
Frank Schwarz completed his undergraduate (1993–1998) and doctoral studies in dentistry
(2001) at the University of Saarland in Homburg/Saar, Germany, where he worked as
a scientific staff member from 1999–2000 at the Department of Periodontology and
Conservative Dentistry under Prof. Dr. E. Reich, the former Director. From 2000 to 2002, he
served as a scientific staff member at the Clinic and Policlinic for Oral and Maxillofacial
Surgery at Ludwig Maximilian's University in Munich (Director: Prof. Dr. Dr. M. Ehrenfeld).
He has been a staff member at the Department of Oral Surgery at Heinrich Heine University
in Düsseldorf (Director: Prof. Dr. J. Becker) since 2002, first as a scientific staff member, and
as the Senior Physician from 2004 until present. He received his certification in Oral Surgery
in 2003, completed his post-doctoral dissertation (Habilitation), was conferred Venia Legendi
(Senior Lecturer) status in the field of Dental, Oral and Maxillofacial Surgery in 2005, and
was appointed Chief Senior Physician in 2006. Dr. Schwarz is a founder of the German Laser
Dentistry Group (AGLZ) and is the author of numerous articles published in national and
international peer-reviewed journals.
Jürgen Becker, Univ. Prof. Dr. med. dent.
Jürgen Becker studied dentistry at the University of Hannover Medical School (MHH
Hannover), where he later completed his doctoral studies at the Department
of Oral and Maxillofacial Surgery. Becker began his career at the Free University of Berlin,
where he worked as an Assistant Dentist (1983) and, later, as Senior Physician (1986) at the
Department of Oral Surgery and Dental Radiology – North (Director: Prof. Dr. P. Reichart).
After receiving his post-doctoral degree (Habilitation)
in 1989, he was appointed Supernumerary Professor in 1994. Professor Becker has served as
Director of the Department of Oral Surgery of Westdeutsche Kieferklinik at the University of
Düsseldorf since 1997. In addition, he was First Chairman of the German Association of
Dental, Oral and Maxillofacial Surgeons from 2001 to 2003. He is on the Scientific Advisory
Board of the German Journal of Dentistry, German Journal of Dental Implantology, and
German Journal of Oral and Maxillofacial Surgery. In 2004, Professor Becker resumed
leadership of the German Task Force on Hygiene Requirements in Dentistry for the
Committee on Hospital Hygiene and Infection Prevention at the Robert Koch Institute in
Berlin.
Preface
As more and more people today are choosing dental implants over traditional methods of
tooth replacement, a corresponding rise in the number of individuals with post-implant
complications can be expected. Consequently, the significance of treating conditions such as
peri-implant infections is mounting. Follow-up studies have shown that the prevalence of
peri-implantitis currently ranges from 12 to 43% for most implant systems. Etiological and
risk factors for the disease have been identified in a number of experimental and clinical
studies performed in recent years. Diagnostic methods borrowed from periodontology have
been adapted and extended to the implant-specific setting. In addition, a number of different
non-surgical and surgical, resective and regenerative modalities are now available for
treatment of peri-implantitis. This book was prompted by the often frustrating realization that
many cases of treatment-resistant peri-implantitis lesions end in implant failure and
explantation. The continuous development of new diagnostic and therapeutic methods has
made it possible to prevent progression of the disease in most cases and to give these patients
a long-term perspective for retention of their implant-borne restorations. Successful
management of peri-implantitis requires a thorough understanding of the underlying medical
and dental factors involved in the overall complex of the disease. Notwithstanding the recent
advances in the field of modern implantology, periodontal regenerative therapy options
should be considered carefully and given preference over implant restorations in certain cases.
F. Schwarz
J. Becker
Contents
1
Anatomy of periodontal and peri-implant tissues
F Schwarz and J Becker
1
1.1
Macroscopic anatomy
1
1.2
1.2.1
1.2.2
1.2.3
1.2.4
1.2.5
Microscopic anatomy of the periodontium 4
Epithelial structures 4
Connective tissue structures 6
Root cementum
6
Alveolar bone 7
Biological width and dentogingival complex
1.3
1.3.1
1.3.2
1.3.3
1.3.4
1.3.5
1.3.6
1.3.7
Bone growth 9
Morphogenic and mitogenic factors 10
Bone metabolism
11
Adaptive bone modeling/remodeling 14
Healing of extraction sockets 16
Bone atrophy 17
Physiological age-related involution 17
Dimensional changes of the alveolar ridge following tooth extraction
7
17
1.3.8 Preservation of the alveolar ridge 21
1.3.8.1 Extraction methods 21
1.3.8.2 Immediate implantation
21
1.3.8.3 Alloplastic semi-analog/root-analog implants
1.3.8.4 Guided tissue and boneregeneration 22
1.4
Microscopic anatomy of peri-implant tissues
1.4.1 Transmucosal aspect 26
1.4.1.1 Epithelial structures 27
1.4.1.2 Connective tissue structures 27
1.4.2 Endosseous part of titanium implants
32
1.4.2.1 The titanium oxide layer in osseointegration33
1.4.2.2 Surface design of the endosseous implant part
1.4.2.3 Initial and early stages of osseointegration 36
1.4.3 Biological width and dentogingival complex
2
21
26
33
40
Etiological factors
45
F Schwarz and J Becker
2.1
Primary etiological factor: Biofilms and plaque accumulation
2.1.1 Development and growth of oral plaque biofilms 46
2.1.2 Ligature-induced peri-implantitis model
49
46
2.2
2.2.1
2.2.2
2.2.3
2.2.4
2.2.5
2.2.6
2.2.7
2.2.8
Additive factors
56
History of periodontitis: microbiology of peri-implant infections 56
Genetic factors
59
Smoking and alcohol consumption 60
Occlusal overload
60
Mucosal conditions 61
Alveolar ridge defects/bone augmentation procedures
62
Gingivitis desquamativa
70
Systemic diseases/medications
71
3
3.1
Pathogenesis of peri-implant infections
F Schwarz and J Becker
Immune defense of infections
75
3.2
Non-adaptive immunity against infections 76
3.3
Adaptive immunity against infections
3.4
3.4.1
3.4.2
3.4.3
3.4.4
4
Histopathological phases of peri-implant inflammations
Early peri-implant mucositis 78
Established peri-implant mucositis 78
Advanced peri-implant mucositis 80
Peri-implantitis
82
Clinical manifestations
87
F Schwarz and J Becker
75
77
78
4.1
Classification of peri-implant bone defects 89
4.2
Radiologic classification
5
Diagnosis
97
F Schwarz, M Herten, K Schwarz, J Becker
5.1
5.1.1
5.1.2
5.1.3
5.1.4
5.1.5
5.1.6
5.1.7
Clinical examinations 97
Index system for plaque biofilms
97
Index system for determination of the condition of peri-implant mucosa 98
Bleeding upon probing
99
Probing depth, gingival recession, clinical attachment level
101
Peri-implant sulcus flow rate 101
Suppuration and pus formation
105
Clinical evaluation of implant mobility
105
5.2
5.2.1
5.2.2
5.2.3
5.2.4
Radiologic diagnostics
Intra-oral radiography
Panoramic radiographs
CT
110
Cone beam DVT
110
5.3
5.3.1
5.3.2
5.3.3
Microbiological and molecular genetics diagnostics
Dark-field microscopy
115
DNA hybridization 115
Polymerase chain reaction 115
5.4
Prevalence of peri-implant infections
92
108
108
108
113
117
5.5
Non-plaque-induced gingival disorders
117
5.5.1 Histopathological examination
120
5.5.2 Exfoliative cytology 123
5.5.2.1 Clinical procedure 123
5.5.2.2 DNA image cytometry
123
5.5.2.3 Diagnostic interpretation of DNA histograms
5.5.2.4 Diagnosis of gingivitis desquamativa
126
125
6
Therapy
129
F Schwarz, A Aoki, A Takasaki, M Sager, A Sculean, J Becker
6.1
Primary objective of therapy 129
6.2
Hygiene phase
130
6.2.1 Optimization of oral hygiene 130
6.2.2 Treatment of periodontal disease
131
6.2.2.1 Fundamentals 132
6.2.2.2 Laser characteristics 132
6.2.2.3 Characteristics of laser radiation
133
6.2.2.4 Laser application to treat periodontal and peri-implant infections 134
6.2.2.5 In vitro studies on laser–tissue interactions of different laser wavelengths 136
6.2.2.6 Lasers: experimental and clinical studies on the treatment of
periodontal disease 142
6.3
Explantation 154
6.4
6.4.1
6.4.2
6.4.3
Corrective phase: nonsurgical initial treatment
161
Mechanical therapy approaches
161
Influence on the morphology and biocompatibility of titanium implants 161
Removal of bacterial plaque biofilms from structured titanium implant
surfaces
164
Antimicrobial and antiphlogistic therapy approaches
169
Histological studies on nonsurgical or surgical treatment of peri-implant
disease 172
Clinical studies: peri-implant mucositis
179
Clinical studies: peri-implantitis
179
6.4.4
6.4.5
6.4.6
6.4.7
6.5
Corrective phase: surgical therapy 189
6.5.1 Decontamination and conditioning of the implant surface 189
6.5.2 Antimicrobial photodynamic therapy
191
6.5.3 General surgical principles 195
6.5.3.1 Incision
195
6.5.4 Surgical-resective therapy approaches
198
6.5.5 Surgical-regenerative therapy approaches 205
6.5.5.1 GTR and GBR
205
6.5.5.2 Requirements of membranes for GBR/GTR methods
206
6.5.5.3 Structure and characteristic features of collagen
207
6.5.5.4 Cross-linking and effects on biocompatibility
208
6.5.5.5 Biodegradation of available collagen membranes 210
6.5.5.6 Biodegradation and angiogenesis 210
6.5.5.7 Bone grafts and graft substitutes
212
6.5.5.8 GBR: histologic examinations
214
6.5.5.9 GBR: clinical examinations 217
6.5.5.10
GBR: histological studies on the treatment of peri-implantitis
6.5.5.11
GBR: clinical studies on the treatment of peri-implantitis 230
6.5.5.12
Soft-tissue management at peri-implantitis sites
252
6.5.5.13
Enamel matrix proteins
261
6.5.5.14
BMPs 262
7
Appendices
267
Appendix 1
Synopsis: Diagnosis of Peri-implant Infections
267
Appendix 2
Synopsis: Risk Assessment – Treatment of Peri-implantitis
Appendix 3
Synopsis: Treatment of Peri-implant Infections
Appendix 4
269
268
222
Documentation – Peri-implant Infections
References
Index 293
271
270