Retrograde Peri Implantitis

2/20/13
Retrograde peri-implantitis
J Indian Soc Periodontol. 2010 Jan-Mar; 14(1): 5765.
PMCID: PMC2933532
doi: 10.4103/0972-124X.65444
Jumshad B. Mohamed, B. Shivakumar,1 Sabitha Sudarsan,1 K. V. Arun,1 and T. S. S. Kumar1
Department of Periodontology and Oral Implantology, Sree Balaji Dental College and Hospital, Uthandi, Chennai, India
1
Department of Periodontics and Implant Dentistry, Ragas Dental College and Hospital, Uthandi, Chennai, India
Address for correspondence: Dr. B. Shivakumar, Department of Periodontics and Implant Dentistry, Ragas Dental College and Hospital,
Uthandi, Chennai, India. E-mail: shivabaskaran/at/rediffmail.com
Revised April 24, 2009; Accepted October 4, 2009.
Copyright Journal of Indian Society of Periodontology
This is an open-access article distributed under the terms of the Creative Commons Attribution License, w hich permits unrestricted use,
distribution, and reproduction in any medium, provided the original w ork is properly cited.
Abstract
Retrograde peri-implantitis constitutes an important cause for implant failure. Retrograde periimplantitis may sometimes prove difficult to identify and hence institution of early treatment may not
be possible. This paper presents a report of four cases of (the implant placed developing to) retrograde
peri-implantitis. Three of these implants were successfully restored to their fully functional state while
one was lost due to extensive damage. The paper highlights the importance of recognizing the
etiopathogenic mechanisms, preoperative assessment, and a strong postoperative maintenance protocol
to avoid retrograde peri-implant inflammation.
Keywords: Implant, retrograde peri-implantitis, regeneration
INTRODUCTION
During the past decade, the use of osseointegrated implants has become an increasingly important
treatment modality for the replacement of missing teeth in fully and partially edentulous patients The
success of osseointegrated dental implants has revolutionized dentistry.[1] With more than three
decades of evidence to support the clinical use of osseointegrated dental implants, implant-related
prosthesis has become a predictable method of replacing missing teeth.[2,3]
The widespread use of these implants has in recent years, produced different types of complications.
Retrograde peri-implantitis, a lesion occurring at the periapical area of an osseointegrated implant, has
recently been described[4] as a possible cause for dental implant failure. The etiology of implant
periapical lesion (IPL) could be attributed to overheating of the bone;[5,6] overloading of the implant;
[7] presence of a pre-existing infection or of residual root particles and foreign bodies in the bone;[8,9]
implant contamination during production or during insertion[10] or placement of the implant.
The usual plaque related or occlusion related peri-implant failure is relatively easily identified when
compared to the retrograde peri-implant lesions. With the ever increasing esthetic demands of patients,
early loading of implants, especially in the anterior segment has become a necessity. As a number of
teeth in the anterior segment are lost due to trauma and other non-periodontal causes, the clinician
must be aware of the potential risk of developing retrograde peri-implantitis due to periapical pathology
in the existing socket/adjacent teeth. This paper presents four cases of retrograde peri-implantits (each
with different etiopathogenic mechanism), three of which were successfully managed and subsequently
www.ncbi.nlm.nih.gov/pmc/articles/PMC2933532/?report=printable
1/21
2/20/13
restored to function. The paper then discusses the possible etiopathogenic mechanism and suggests
guidelines for the early identification and management of peri-implantitis.
CASE SERIES
Case I [Figure 1a to 1j]
A 42-year-old female patient presented with a history of failed endodontics followed by extraction and
socket preservation in relation to #31 six months prior to reporting to the implant clinic. The adjacent
teeth #32 and #41 showed endodontic restorations. After clinical and radiological evaluation it was
decided to place a 3.0 12 mm single piece implant$ . Adequate primary stability was obtained at the
time of placement. When reviewed after six weeks, the site showed signs of abscess formation in the
alveolar mucosa in relation to implant #31. There was no evidence of probing depth around the
implant, but radiographs revealed peri-implant bone loss at the middle third region. The implant was
found to be stable with no mobility. Open flap debridement was done and the implant surface
decontaminated with universal implant deplaquer$$ . The implant was subsequently followed up for a
period of one year with regular three-month clinical and radiological reviews.
Discussion The normal peri-implant sulcus depth and absence of other inflammatory signs in the peri-
implant mucosa suggests that anterograde peri-implantits was not the cause for bone loss observed in
this case. Even though endodontic therapy was performed in the adjacent teeth, placement of implant
might have triggered latent periapical pathology[11,12] from the adjacent teeth. Recent evidence
suggests the existence of an autoimmune response[13,14] in the periapical area in relation to an antigen
which may be microbial in origin. The host response that is triggered off, may affect the host tissues as a
result of similarity between the microbial and the host antigens, such as the heat shock proteins. In
such instances, even after thorough debridement of the root canal has resulted in elimination of the
microbial antigens, the host response may ensure continuation of an active inflammatory process.
The process of implant placement could result in activation of this latent response either due to
overheating or contamination or a combination of both. This activation could have resulted in the rapid
bone loss in a short period of time. The importance of periodic clinical and radiographic examination of
implants that are placed adjacent to endodontically treated teeth has to be emphasized and a shorter
recall program has to be instituted to identify and manage retrograde peri-implant bone loss in its early
stages.
Case II [Figure 2a to 2j]
An 18-year-old male presented with a history of trauma two weeks prior to presentation resulting in
avulsion of tooth #21. After clinical and radiological evaluation a 3.0 15 mm single piece implant$
was placed with adequate primary stability. In two weeks time patient presented with signs of periimplant abscess formation and mobility of the implant in relation to tooth #21. Radiograph revealed
peri-implant bone loss at the apical third as well as the adjacent tooth #22. Open flap debridement was
done with universal implant deplaquer$$ and the osseous defect was filled with calcium phosphate and
Hydrase# . Tooth #22 was endodontically treated. The implant was subsequently followed up for a
period of one year with regular three-month clinical and radiological reviews.
Discussion In this case, the implant was placed in an avulsed site adjacent to tooth #22 that exhibited
signs of trauma (Ellis class II fracture). The tooth was tested for vitality using the EPT (electric pulp
tester), which revealed the presence of a vital pulp. Subsequently, the implant placement was
undertaken without endodontic therapy in tooth #22. This case illustrates the limitations of using the
EPT (which is actually an indicator of nerve stimulation) when testing the vitality of the tooth. The
undetected pericapical pathology flare following implant placement resulting in the retrograde periimplant lesion is identified in this case. The fractured tooth adjacent to an edentulous site must be
2/21
2/20/13
critically evaluated for evidence of dormant periapical lesions[14] and the results obtained from EPT
may not be considered a gold standard for vitality of the pulp. In suspected cases where the fracture line
is close to the pulp, it may be prudent to consider intentional endodontic therapy prior to implant
placement regardless of the results obtained from the EPT.
Management of the peri-implantitis was performed as stated by Tzm M et al,[9] and Pearrocha
Diago M et al,[8] by treating the periapical implant pathology and the adjacent natural tooth without
the removal of the implant. The treatment procedure included root canal treatment followed by the
debridement of the apical bone lesion, and guided bone regeneration. Smaller peri-implant lesions heal
well even without a placement of bone replacement graft; however, in larger defects it may be prudent
to place these materials to enhance healing. The placement of the graft (calcium phosphate) allowed
greater chance for new bone formation as otherwise repopulation of the wound site by gingival cells,
could result in a fibrous rather than osseous healing.
Case III [Figure 3a to 3k]
A 38-year-old male presented with a history of treated chronic periodontitis and missing teeth #31 and
#41. Clinical and radiological examination revealed inadequate ridge width for implant placement;
hence block graft augmentation was performed with a ramus block graft at the site. After 6 months,
two 3.0 15 mm single piece implant$ was placed in relation to #31 and #41 with adequate primary
stability. At one-month review abscess formation was noticed around implant #31 with mobility.
Implant #41 was intact with no signs of peri-implantits. Radiographic examination revealed periimplant bone loss at the apical third as well as the adjacent tooth #32. A flap was raised and thorough
debridement was done with universal implant deplaquer$$ followed by placement of bioceramic bone
graft## and collagen membrane* along with endodontic restoration of tooth #32 on the same day. The
implant was subsequently followed up for a period of one year with regular three-month clinical and
radiological reviews.
Discussion Existence of active periodontal inflammation in the adjacent teeth is one possible
etiopathogenic mechanism[15] responsible for periapical pathology and subsequent spread of infection
to involve peri-implant tissue in a retrograde manner. Existing periodontal disease must be scrutinized
carefully to ensure resolution of the active inflammatory lesion before implant placement is undertaken.
The usual clinical parameters of BOP, PD, and CAL have to be repeated serially after
surgical/nonsurgical periodontal therapy to ensure stability of the periodontium prior to implant
placement.
Case IV [Figure 4a to 4f]
A 25-year-old male patient presented with a history of failed endodontic therapy in relation to tooth #11
and subsequent extraction 6 months prior to presentation to implant clinic. Clinical and radiologic
examination revealed adequate hard and soft tissue dimensions for implant placement. A 3.0 15 mm
single piece implant$ was placed in relation to #11 with good primary stability. In two weeks time
patient presented with signs of peri-implant mucositis and mobility. The implant was removed the
subsequent week.
Discussion The existence of a periapical pathology necessitated extraction of the tooth after failure of
endodontic therapy. Although there was no radiographic evidence of any pathology in the periapical
region at the site of implant placement, the previous periapical pathology[16,17] had obviously not
resolved. These sites may be considered to be at greater risk for implant placement and underlies the
value of evaluation of the suspected sites with more sensitive investigative procedures such as CT scan.
Economic considerations may preclude the use of such procedure routinely, but the suspected sites have
to be evaluated with CT scan to avoid such retrograde implant failures.
3/21
2/20/13
CONCLUSION
Retrograde peri-implantits constitutes an important source of implant failure. Careful preoperative
evaluation of the site, adjacent teeth, and postoperative assessment of the implant placed could reduce
the chances of development of retrograde peri-implantitis. Once diagnosed, the lesion has to be treated
aggressively rather than by observation and conservative management.
$
BioHorizons Maximus Single Piece Implant
$$ Universal Implant Deplaquer (Straumann)

#
Regen Biocement and Hydrase (Steiner Laboratories)
## Grabio Glascera
* Healiguide membrane
Footnotes
Source of Support: Nil
Conflict of Interest: None declared.
REFERENCES
1. Klokkevold PR, Newman MG. Current status of dental implants: A periodontal prospective. J Oral
Maxillo Implants. 2000;15:5665.
2. Lekholm U, Gunne J. Survival rate of Branemark implants in partially edentulous jaws: A 10 year
study. Int J Oral Maxillofac Implants. 1999;69:63945. [PubMed: 10531735]
3. Lekholm U, Adell R, Eriksson B, Brnemark PI, Jemt T. Long-term follow-up study of
osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants.
1990;5:34759. [PubMed: 2094653]
4. Ayangco L, Sheridan PJ. Development and treatment of retrograde peri-implantitis involving a site
with a history of failed endodontic and apicoectomy procedures: A series of reports. Int J Oral
Maxillofac Implants. 2001;16:4127. [PubMed: 11432661]
5. Augustin G, Davila S, Udiljak T, Vedrina DS, Bagatin D. Determination of spatial distribution of
increase in bone temperature during drilling by infrared thermography: Preliminary report. Arch
Orthop Trauma Surg. 2009;129:7039. [PubMed: 18421465]
6. Lavelle C, Wedgewood D. Effect of internal irrigation on frictional heat generated from bone drilling.
J Oral Surg. 1980;38:499503. [PubMed: 6929901]
7. Jalbout ZN, Tarnow DP. The implant periapical lesion: Four case reports and review of the literature.
Pract Proced Aesthet Dent. 2001;13:10712. [PubMed: 11315428]
8. Pearrocha Diago M, Boronat Lpez A, Lamas Pelayo J. Update in dental implant periapical surgery.
Med Oral Patol Oral Cir Bucal. 2006;11:42932.
9. Tzm TF, Senimen M, Ortakolu K, Ozdemir A, Aydin OC, Kele M. Diagnosis and treatment of a
large periapical implant lesion associated with adjacent natural tooth: A case report. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2006;101:1328.
10. Piattelli A, Scarano A, Piattelli M, Podda G. Implant periapical lesions: clinical, histologic, and
histochemical aspects: A case report. Int J Periodontics Restorative Dent. 1998;18:1817.
[PubMed: 9663096]
11. Kishen A. Periapical biomechanics and the role of cyclic biting force in apical retrograde fluid
4/21
2/20/13
movement. Int Endod J. 2005;38:597603. [PubMed: 16104972]

12. Quirynen M, Gijbels F, Jacobs R. An infected jawbone site compromising successful
osseointegration. Periodontology 2000. 2003;33:12944. [PubMed: 12950847]
13. Carneiro E, Menezes R, Garlet GP, Garcia RB, Bramante CM, Figueira R, et al. Expression analysis
of matrix metalloproteinase-9 in epithelialized and nonepithelialized apical periodontitis lesions. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:12732. [PMCID: PMC2742315]
[PubMed: 18926740]
14. Wahlgren J, Salo T, Teronen O, Luoto H, Sorsa T, Tjderhane L. Matrix metalloproteinase-8 (MMP8) in pulpal and periapical inflammation and periapical root-canal exudates. Int Endod J.
2002;35:897904. [PubMed: 12453017]
15. Ong CT, Ivanovski S, Needleman IG, Retzepi M, Moles DR, Tonetti MS, et al. Systematic review of
implant outcomes in treated periodontitis subjects. J Clin Periodontol. 2008;35:43862.
[PubMed: 18433385]
16. Nobuhara WK, Del Rio CE. Incidence of periradicular pathoses in endodontic treatment failures. J
Endod. 1993;19:3158. [PubMed: 8228754]
17. Chaffee NR, Lowden K, Tiffee JC, Cooper LF. Periapical abscess formation and resolution adjacent
to dental implants: A clinical report. J Prosthet Dent. 2001;85:10912. [PubMed: 11208196]
Figures and Tables

Figure 1a
Preoperative photograph
Figure 1b
5/21
2/20/13
Preoperative radiograph
Figure 1c
6/21
2/20/13
Six week photograph

Figure 1d
7/21
2/20/13
Six week radiograph

Figure 1e
Operative photograph
Figure 1f
Six month photograph

Figure 1g
8/21
2/20/13
Six month probing

Figure 1h
Six month radiograph

Figure 1i
9/21
2/20/13
One year photograph

Figure 1j
10/21
2/20/13
One year radiograph

Figure 2a
Preoperative photograph
Figure 2b
11/21
2/20/13
Figure 2c
Two week photograph

Figure 2d
Two week radiograph

Figure 2e
12/21
2/20/13
Figure 2f
Bone graft placed

Figure 2g
13/21
2/20/13

Figure 2h

Figure 2i
One year photograph

Figure 2j
One year radiograph

Figure 3a
Figure 3b
Radiograph showing block graft

Figure 3c
14/21
2/20/13
Four weeks photograph

Figure 3d
15/21
2/20/13
Four weeks radiograph

Figure 3e
16/21
2/20/13
Figure 3f
Bone graft placed

Figure 3g
Membrane placed
Figure 3h
17/21
2/20/13
Six month photograph

Figure 3i

Figure 3j
18/21
2/20/13
One year photograph

Figure 3k
19/21
2/20/13
One year radiograph

Figure 4a
Immediate postoperative photograph

Figure 4b
Immediate postoperative radiograph

Figure 4c
Two week photograph

20/21
2/20/13
Figure 4d
Two week radiograph

Figure 4e
Three week photograph

Figure 4f
Three week radiograph

Articles from Journal of Indian Society of Periodontology are provided here courtesy of Medknow Publications
21/21

Retrograde Peri Implantitis

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Retrograde Peri Implantitis

Hochgeladen von

Copyright:

Verfügbare Formate

2/20/13

J Indian Soc Periodontol. 2010 Jan-Mar; 14(1): 5765.

BioHorizons Maximus Single Piece Implant

$$ Universal Implant Deplaquer (Straumann)

Regen Biocement and Hydrase (Steiner Laboratories)

movement. Int Endod J. 2005;38:597603. [PubMed: 16104972]

Figures and Tables

Six week photograph

Six week radiograph

Six month photograph

Six month probing

Six month radiograph

One year photograph

One year radiograph

Two week photograph

Two week radiograph

Bone graft placed

Six month radiograph

Six month radiograph

One year photograph

One year radiograph

Radiograph showing block graft

Four weeks photograph

Four weeks radiograph

Bone graft placed

Six month photograph

Six month radiograph

One year photograph

One year radiograph

Immediate postoperative photograph

Immediate postoperative radiograph

Two week photograph

Two week radiograph

Three week photograph

Three week radiograph

Das könnte Ihnen auch gefallen