CONSENSUS STATEMENTS S105

Marco Esposito, Björn Klinge, Joerg Meyle, Andrea Mombelli, Eric Rompen, Daniel van Steenberghe, Tom Van Dyke, Hom-Lay Wang, Arie Jan van Winkelhoff Working Group on the Treatment Options for the Maintenance of Marginal Bone Around Endosseous Oral Implants, Stockholm, Sweden, 8 and 9 September 2011 Consensus Statements

Preventive measures lack of sufficient bone volume and unknown reasons. It must be distinguished from marginal • Pretreatment of patients who are candidates for bone loss occurring during the subsequent main- oral rehabilitation by means of implants should tenance phase. The baseline measurements for involve comprehensive treatment planning; sani- eventually detecting marginal bone loss are the tation of the entire oropharyngeal cavity; dealing radiographs taken at or within weeks after the with periodontal, periapical or other endosseous installation of the prosthetic suprastructure. When inflammatory lesions; smoking cessation; and the suprastructure is placed in conjunction with dealing with parafunctional habits. To achieve the implant surgery, radiographs for baseline this, a multidisciplinary approach seems relevant. assessment should be taken ±3 months later. • There is limited evidence for a short-term benefit • Peri-implantitis is a destructive inflammatory (±0.5 mm) of platform switching for the main- process around osseointegrated implants. It is tenance of marginal bone. characterised by pocket formation and loss of • Although the impact is limited, one should be supporting bone. Diagnosis of peri-implantitis is aware that repeated removal of an abutment based on pocket probing, assessing bleeding on integrated in the gingival/mucosal soft tissue probing and radiographs. as may result in more or is a risk factor for marginal such does not necessarily indicate peri-implantitis. bone loss (±0.2 mm). Bleeding can also be observed in peri-muco sitis • Patients in whom oral implants are inserted should when a stable soft tissue inflammation occurs. be kept on a strict maintenance pro- • Marginal bone loss of ≥2 mm compared to ini- gram and encouraged to quit smoking. The main- tial radiographs, at suprastructure installation or tenance frequency should also be based on the within the first 3 months, associated with bleed- patient’s susceptibility to destructive periodontal ing on probing of the peri-implant pocket should inflammation and the smoking habit (>10 cigar- lead to further examinations, such as radiographs ettes/day). Professionals with sufficient experience to confirm or not the suspicion of peri-implantitis. in periodontal care should preferably be involved. • When exudate from the peri-implant pocket is noticed, a thorough clinical diagnosis should aim at determining the aetiology. This should include Diagnostics pocket probing, radiographs (to check for fractures of implant components, abutment loosening, sub- • Marginal bone loss occurring at, or soon after, im- gingival cement or other foreign bodies), occlusal plant placement can be caused by surgical trauma, assessment and eventually microbial testing.

Eur J Oral Implantol 2012;5(Suppl):S105–S106 S106 Working Group Marginal bone maintenance around oral implants

Therapeutic approaches ucts that have been successfully tested at the clin- ical level may not be available in several countries. • The clinical evidence for effective treatment regi- • There is very limited clinical data available on the mens in the presence of peri-implantitis remains effects of systemic antibiotics in the treatment of insufficient, which does not mean that the cur- peri-implantitis. rently used interventions cannot be effective. • In deep peri-implantitis lesions, a surgical inter- • For the decontamination of the infected im- vention provides better access and may allow for plant surface, rinsing with saline or cotton pellets the changing of peri-implant tissue morphology soaked with saline, mechanical of to stabilise the site or to promote the regener- the surface, and Er:YAG laser treatment seem ation of bone. equally efficient. Implantoplasty below the gin- • In more than half of the cases, peri-implantitis gival level during open flap surgery can also be therapy does not lead to a resolution of the infec- performed, especially when deep pockets are tion and long-term success for the patient. present. However, no sufficient clinical evidence • Since host modulatory approaches are successful for this intervention is available. for periodontitis, they will likely be applicable to • The surface structure of presently available im- peri-implantitis. Treating peri-implant inflamma- plant systems may have an impact on the pro- tory diseases with one or more lipid mediators gression of marginal bone loss, but scientific may be another option. evidence does not reveal any significant impact of this parameter on the failure or success of peri- implantitis therapy. Future research • Marginal bone loss as such is not an indication for implant removal unless it is in such an advanced Priorities for future clinical research on prevention/ stage that it renders more conservative treatment treatment of marginal bone loss around implants should options questionable. focus on randomised clinical trials to assess whether • Thorough submucosal debridement, implant sur- • systemic antibiotic regimens have a beneficial face disinfection and oral hygiene are the cor- effect as an adjunct therapy to implant surface nerstones of peri-implantitis treatment. Systemic instrumentation and/or respective or regenera- antibiotics may be beneficial as an adjunct to tive peri-implant surgery such treatments but never a substitute. • surgical approaches are superior to non-surgical • In partially edentulous patients, the treatment of ones to re-establish a healthy interface between periodontitis seems a logical prerequisite consider- an implant surface and surrounding tissues ing the evidence for possible cross-contamination • axially oriented implants lead to better mainten- of subgingival areas around implants. Effective ance of the marginal bone versus angulated ones periodontal treatment of the remaining dentition is • splinted implants lead to better maintenance of a prerequisite to prevent or stabilise inflammatory the marginal bone level than non-splinted ones reactions around transmucosal implants. • increasing the number of implants sustaining a • A decrease of the bacterial load in the peri-implant prosthetic suprastructure maintains a better mar- pocket may be enough to establish equilibrium ginal bone level with the host defence. The implant surface may • host-modulatory therapy maintains a better mar- however still not be biocompatible enough for a ginal bone level. direct re-apposition of bone. There are no clinical trials with sufficient power to demonstrate that Prospective studies should identify re-osseointegration occurs in patients. • the possible role of occlusal overload on the fate • Local antibiotics of the tetracycline group, associ- of marginal bone around implants ated with a slow-release device as an adjunct to • whether increased bone turnover in postmeno- mechanical debridement, may arrest the progres- pausal women has an impact on the marginal sion of peri-implantitis lesions. Some of the prod- bone.

Eur J Oral Implantol 2012;5(Suppl):S105–S106