Implantology

A CLINICAL STUDY ON THE INCIDENCE AND MANAGEMENT OF

BIOLOGICAL COMPLICATIONS IN IMPLANT THERAPY

Nicolae VASILE1

Associate Professor,”Lucian Blaga” University of Medicine, Faculty of Dental Medicine, Dept. Dental Prosthetics, Sibiu, Romania
1

Corresponding author: dento_medica@yahoo.ro

Abstract implant-prosthetic medical team should be

The scope of the study was to evidence the methods
capable of recognizing the possible risk factors,
recommended for avoiding, managing and implementing in view of a successful treatment. Identification
an efficient treatment capable of reducing the biological and limitation of biological complications are
complications accompanying implant therapies. mainly aimed at minimizing risks and at reducing
Materials and method. The study evaluates the patients
with prosthesis charged implants - or during their morbidity in patients.
osseointegration period - inserted in the Clinic of The Several studies showed that the implant-
Emergency Military Hospital of Sibiu, over a 5 year period prosthetic therapy is always facing biological,
(2009-2014). Retrospective investigation was based on the
technical and aesthetic complications, many of
evaluation of the treatment files and on the imagistic and
clinical analyses of the 125 patients to whom 385 implants them directly related with the patient, such as:
had been inserted. • the healing capacity of each person in part,
Results and discussion. The study demonstrates that, • the ability of understanding the importance
when implants are the support of an overdenture,
surrounded by either limited keratinized gingiva or mobile
of the treatment and of its monitoring,
tissues, the presence of the bacterial plaque is considerable, • the necessity of an individual oral care.
the peri-implant pocket exceeds 5 mm, and sensitivity and
bleeding are produced on contact with the probe. In Many complications have an iatrogenic
susceptible patients, or in those with pathological
periodontal antecedents, the re-infection potential has been component, for example those occurring in
always higher. The clinical study confirms that, invariably, planning or execution of the surgical stage.
peri-implantitis is associated with the existence of the Consequently, the requirements of implant
bacterial plaque and also with the presence of a peri-
implant pocket exceeding 4 mm (8.9%), with partial
surgery in the aesthetic region assume a rich
exposure of the covering screw (4.5%) and fixed surgical experience in various domains, such as
restaurations without self-cleaning spaces (2%). bone or soft tissue augmentation, prosthetic and
Conclusions. Out of the post-surgery biological occlusological knowledge, as well as experience
complications, peri-implantitis is the most frequent one,
causing a – sometimes total – loss of the alveolar bone in periodontal treatments and treatment of
around the osseointegrated implant. implant mucositis and peri-implantitis. As an
Keywords: biological complications, peri-implant infections, inflammatory process, periodontitis may affect
implant therapy
dental implants – by peri-implantitis, and, as an
untreated periodontitis finally leads to the loss
1. INTRODUCTION of the natural teeth, it may also cause the loss of
dental implants [1].
The therapy on implants represents an option The etiology of peri-implantitis may be
of prosthetic restoration with increased established as early as the selection of patients
predictability and high rate of success, resulting for implant treatments. 86% of the patients
either from post-extraction insertion or from suffering from peri-implantitis have an
implant insertion in previously edentulous unsatisfactory oral hygiene or are responsible for
zones. an incorrect application of the maintenance
Avoidance and management of complications techniques of the prosthetic devices, thus
are part of the clinical practice, whereas the favouring the development of bacterial plaque.

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 A CLINICAL STUDY ON THE INCIDENCE AND MANAGEMENT OF BIOLOGICAL COMPLICATIONS IN IMPLANT THERAPY

The biofilms formed on either teeth or therapeutic protocol for combating possible
implants, or the bacterial plaque are formed of complications and the objectives of the procedures
complex microbial colonies, included in a matrix for maintaining the health condition of the peri-
of polymers derived from bacteria and saliva. implant tissues. The cases of peri-implantitis
Plaque bacteria are the main etiological factors under treatment were between 3 and 7 years.
in the development of peri-implantitis, while the
biofilms from the implant surfaces are described 3. RESULTS AND DISCUSSION
as the chief source of the pathogenic phenomena
developed around the implants – actually, one
Selection of the aggregation solution of
of the major causes of their loss.
prosthetic restauration may influence the health
In cases of prosthetic dies on implants, the
condition of the peri-implant tissues; 12% of the
marginal depths should be of 0.5 mm lingually,
causes of soft tissue inflammation were related
1 mm mesially and distally and 1.5 mm
to the presence of residual cement.
vestibularly, respectively, as these spaces will
The possibility to remove the cement retained
assure both masking of the junction between the
after the final aggregation of restoration is a
dies and restoration, and an adequate access for
serious argument against the application of
cement cleaning. [2]
cemented crowns on dies. Hermanides [4]
Several clinical studies stated that the absence
recommends a subgingival placement of crowns,
of keratinized gingiva is associated with a
not farther than 1.5 mm under the gingival
statistically significant increase of either bone
margin.
loss or attachment, comparatively with the
In cases of prosthetic dies on implants, the
keratinized gingiva zones [3].
marginal depths should be of 0.5 mm lingual, 1
The scope of the study was to evidence the
mm mesial and distal and 1.5 mm vestibular,
methods for avoiding, managing and
respectively, as these spaces will assure both
implementing an efficient treatment capable of
masking of the junction between the dies and
reducing the biological complications
restoration, and an adequate access for cement
accompanying implant therapies, for granting
cleaning. [2]
the oral health, comfort, functionality and
As most of the restorations analyzed in the
aesthetics of patients.
present study are stabilized through cementation,
a main concern of ours was to identify the
2. MATERIALS AND METHOD
presence of the retained cement in the peri-
implant ditch, 24 cases in which this presence
The study evaluated the patients with caused peri-implant inflammation being
prosthesis charged implants or during their evidenced.
osseointegration period, inserted in the Clinic of A prosthesis cemented on implants should
The Emergency Military Hospital of Sibiu, over meet the following criteria:
a 5 year period (2009-2014). Also included in the • the maturated and keratinized peri-
study were patients with implants inserted in implant gingiva should be at a minimum distance
other dental offices, suffering from peri-implant of 2 mm from the peri-implant sac,
biological complications, to whom therapies and • placing of dies plate at a maximum
protocols of peri-implant maintenance had been distance of 2 mm from the final free gingival
applied. margin,
The retrospective investigation was based on • utilization of semi-soluble cements
the evaluation of the treatment files and on the • the emergence profile of the curved-shaped
imagistic and clinical analyses of the 125 patients dies and the complete removal of the cement.
to whom 385 implants had been inserted. In some situations (9 cases), the cemented
The files of the patients affected by peri- worked had to be removed and replaced, the
implant problems recorded the protocol of the cause being a difficult peri-implant approach,
inflammation indices of soft tissues, the which prevented stopping of peri-implant

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Nicolae VASILE

phenomena. As a matter of fact, the necessity of The present study confirms that peri-
recovering a prosthesis cemented on the implant implantitis is an affection with a symptomatology
may be caused by a loosened screw, by an incorrect similar to that of chronic diseases, more precisely
adaptation of the margin of the crown to the it is not associated with the general signs or
margin of the die, fractured ceramics, peri-implant symptoms of infection or of bacteriemia.
bone resorption, impossibility of cement removal, Only two cases of acute infection were
or peri-implantitis impossibly to be healed. identified – a peri-implant abscess and peri-
The biofilms formed on teeth, implants or implant cellulitis with sinus invasion, that may
bacterial plaque are complex microbial colonies be characterized as being of polymicrobial
included in a matrix of polymers derived from nature, with a strong immune response, oedema,
bacteria and saliva. pain and functional disorders.
For now, the mechanism through which oral Oral infections have a polybacterial nature,
bacteria adhere to the solid surfaces is not fully 5% of them are caused by aerobic germs, 35% are
elucidated, however, in the oral cavity, a pellicle anaerobic, and 60% are associated.
formed through absorption of the salivary Aerobic bacteria are dominated by gram
components gets attached to the surface of the positive cocci (streptococci and staphylococci),
trans-gingival dies. The mechanism continues whereas the anaerobic bacteria are anaerobic
through the interface of oral bacteria with these cocci (peptostreptococci) and gram negative
biological adhesions by their fixation onto the anaerobic bacilli [6].
dental or implanting surfaces [5]. In view of standardization, measurements of
Periodontal or peri-implant infections are a inflammation involved evaluation of the bleeding
component of the sub-clinical oral-facial index, of the index of bacterial plaque, depth of
infections, which proves that the immune the peri-implant pocket and width of the
response controlled the bacterial attack, no keratinized gingiva surrounding the implants.
clinical signs of infection: erythema, tumefaction, The keratinized gingiva plays an important
being present. If the inflammatory process is not role in implant sealing with fibrous and epithelial
treated, tissue destruction occurs, a situation tissue, as most of the implants affected with peri-
considered as a disease [6]. implantitis had a mobile gingiva, pseudo-
attached onto implants. In this respect, absence
of the keratinized tissue (< 2 mm) was registered,
and several researchers reported a statistically
significant increase of the inflammation degree,
comparatively with the areas of keratinized
gingival tissue, exceeding 2 mm [3].
The study demonstrates that, if the implants
are the support of an overdenture, and a narrow
keratinized gingiva occurs around them, or if the
implants are surrounded by mobile tissues, the
bacterial plaque is considerable, the peri-implant
pocket exceeds 5 mm, and sensitivity and
bleeding appear on probe touching.
Mucous irritation and accumulation of
bacterial plaque is visible in senior patients with
a scarce oral hygiene. Most of the failures were
caused by the infections produced around
implants with ball systems for maintaining the
detachable prostheses, when occlusal stress is
added to the mucosal infections generated by
their movements.
Fig. 1. Advanced bone resorption

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 A CLINICAL STUDY ON THE INCIDENCE AND MANAGEMENT OF BIOLOGICAL COMPLICATIONS IN IMPLANT THERAPY

uncovering of the deficitary slope or the

absence of graft integration, when this had
been applied for correcting the defect.
Peri-implant inflammation is more
frequently occurring where the implant had
not been covered by the flap, an incorrect
irrigation of the flap and of the adjacent bone
being observed when the too thin vestibular
wall was resorbed, leaving the surface of the
implant in contact only with the fibro-mucous
structure. Loss of the vestibular bone and
deepening of the peri-implant pocket was more
frequent in positions in which the implants
with a large diameter (4.5 mm) were placed in
alveolar ridges with inadequate width (below
6 mm).
In susceptible patients or in those with
periodontal pathological antecedents, the
Fig. 2. Clinical aspect of peri-implantitis
re-infection potential was always higher. The
The two factors of osseointegration loss, presence of some periodontal pockets on the
namely peri-implantation and biomechanical natural teeth, even on those subjected to
stress, are difficult to evaluate separately. If mechanical debridement for the elimination of
the peri-implant infection may appear prior to the periodontal pathogenic risk, does not
prosthetic charges, in implants which support maintain, nor does it prevent progression of
prosthetic structures, the biomechanical the disease, which may be easily transferred
component appears as one of the causes of the towards the peri-implant sulcus.
implant therapy failure. The implants The multi-factorial etiology has a
supporting detachable prostheses are more preponderantly local component (bacterial
liable to failure, comparatively with single plaque and occlusal overstressing), as well as
tooth dental implants, in which the a series of general (smoking, decompensated
biomechanical factor is more reduced; if neither diabetes, osteoporosis) or local (periodontal
inflammation nor stress induces significant disease, oral hygiene, mucosal hyperplasia)
bone losses when acting individually, favouring factors [8].
association of the two factors represents a Patients suffering from peri-implantitis
disastrous combination [7]. were subjected to a program of peri-implant
Comparatively with the other specialty soft tissue care and it were only those who did
studies of the field, the low ratio (16%) of not observe the medical indications (usually
mucosal peri-implantitis (mucositis) evidences coming from other dental offices) that lost their
the reduced interest of the patient for a implants, while the re-infection potential is
periodical medical program and application of always present in susceptible patients. In such
the techniques of individual oral care. A high cases, techniques of peri-implant maintenance
frequency of inflammation around the implants and prevention have been applied, along with
was also observed in patients with mixed multimodal therapeutic procedures, including
implant-prosthetic prostheses, when the utilization of saline solutions, solutions with
natural teeth were affected by rebellious soluble antibiotics, chlorhexidine (solution and
periodontal disease or when biomechanical gel – 0.12%) local antibiotics (spherical
overcharge occurs. Another local risk factor monocyclines with slow release - Arestin) with
identified for peri-implantitis was the height direct antibacterial and anti-inflammatory
of the alveolar ridge, unequal at the level of the local effect, insertion of dexamethasone in the
implant site, accompanied by a premature peri-implant pocket, decontamination of

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Nicolae VASILE

implant surface with gel of citric acid, 4. CONCLUSIONS

chlorhexidine cones with slow release. The
surgical interventions involved local Out of the post-surgery biological complications,
debridement and application of reconstructive peri-implantitis is the most frequent one, causing
and regenerative techniques of bone resection, loss – sometimes total - of the alveolar bone
with apical repositioning of the flap, bevel of around the osseointegrated implant.
the alveolar bone, addition of xenogeneic bone
References
graft (Bio- Oss) with no mixture of autogenous
bone, post-surgery monitoring, systemic 1. Misch C. Dental Implant prosthetics. St. Louis
antibiotherapy (600 mg clindamycin each 12 h, (MO):Mosby; 2005.
or 2g amoxicillin/day and metronidazol), 2. Schoenbaum TR, McLaren EA. Retrieval of a
defective cement-retained implant prosthesis.
irrigations with chlorhexidine 2 times a day for
Compendium. 2013; 34:692-6.
2-3 weeks and updating of the oral hygiene 3. Hildebrand D, Gollner M, Schermeier O, Nelson K.
instructions. Orale Implantologie in Zeiten der OP-Navigation.
Clinical studies confirm that, invariably, Quintessentz Team-Journal. 2002; 32(10).
peri-implantitis is associated with the 4. Hermanides L. Managing the Technical and Biologic
occurrence of the bacterial plaque, and also Success of an Implant Abutment. Inside Dental
Technology. 2014; 5(5).
with the presence of a peri-implant pocket
5. Philips K, Mitrani R. Implant Management for
larger than 4 mm (8.9%), partial exposure of Comprehensive Occlusal Reconstruction.
the covering screw (4.5%) and fixed restorations Compendium. 2001; 22(3):235-245.
without self-cleaning spaces (2%). 6. Esposito M, Hirsch JM, Lekholm U, Thomsen P.
Implant exposure through dehiscence is a Differential Diagnosis and Treatment Strategies for
consequence of some errors made in the final Biologic Complications and Failing Oral Implants:
A Review of the Literature. Int J Oral Maxillofac
surgical stage, such as: incomplete implant
Implants. 1999; 14: 473- 490.
insertion, flap tension or oedema and prolonged 7. Misch CE. Early crestal bone loss etiology and its
sub-mucosal hematoma [9]. effect on treatment planning for implants. Postgrad
In susceptible patients – which suffer from Dent. 1995; 2:3-17.
a severe periodontal disease – a periodical and 8. Nicolae V, Covaci L. Prosthetic Restorations in Oral
careful evaluation is recommended, at well- Implantology [Restaurări protetice în Implantologia
Orală]. Sibiu: Lucian Blaga University Publishing
determined time intervals, for an early
House; 2010
recognition of a peri-implant infection, and for 9. Nicolae V, Covaci L. Surgical Approaches in Oral
the establishment of a rigorous therapeutic Implantology [Abordări chirurgicale în Implantolo-
protocol and the most suitable measures to be gia Orală]. Sibiu: Lucian Blaga University Publi-
taken. shing House; 2009.

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