Implant periapical lesion: diagnosis and treatment

Treatment and Resolution of an Implant Periapical Lesion (IPL) with Guided Bone Regeneration

Background

Implant periapical lesion (IPL) is a rare condition that can affect dental implants. Several different approaches have been proposed for the treatment of this condition. Awareness and literature discussing this condition and possible treatment options have grown significantly in the last 25 years. Case Presentation. The present case report describes the treatment of an implant periapical lesion with a combined approach consisting of surgical lesion removal, mechanical instrumentation with titanium brush, detoxification with tetracycline, and guided bone regeneration (GBR) with demineralized allograft bone and cross-linked collagen membrane. The patient was followed up for 6 months postoperatively, showing complete resolution of the buccal fistula. No signs or symptoms of discomfort or pathology were reported.

Conclusions

The case report presented a combined approach that can be successful in the surgical treatment of an IPL in which the implant stability is maintained.

A novel histopathological classification of implant periapical lesion: A systematic review and treatment decision tree

BACKGROUND

Implant periapical lesion (IPL), as a peri-implant disease originating from implant apex, maintains coronal osseointegration in the early stage. With the understanding to IPL increasingly deepened, IPL classification based on different elements was proposed although there still lacks an overall classification system. This study, aiming to systematically integrate the available data published in the literature on IPL associated with histopathology, proposed a comprehensive classification framework and treatment decision tree for IPL.

METHODS AND FINDINGS

English articles on the topic of "implant periapical lesion", "retrograde peri-implantitis" and "apical peri-implantitis" were searched on PubMed, Embase and Web of Science from 1992 to 2021, and citation retrieval was performed for critical articles. Definite histopathology and radiology of IPL are indispensable criteria for including the article in the literature. The protocol was registered in PROSPERO (CRD42022378001). A total of 509 papers identified, 28 studies were included in this review. In only one retrospective study, 37 of 39 IPL were reported to be at the inflammatory or abscess stage. 27 cases (37 implants) were reported, including acute non-suppurative (1/37, developed to chronic granuloma), chronic granuloma (5/37), acute suppurated (2/37), chronic suppurated-fistulized (6/37), implant periapical cyst (21/37), poor bone healing (2/37), foreign body reaction (1/37). Antibiotics alone did not appear to be effective, and the consequence of surgical debridement required cautious interpretation because of the heterogeneity of lesion course and operation. Implant apicoectomy and marsupialization were predictable approaches in some cases.

CONCLUSIONS

The diversiform nature of IPL in the case reports confirms the need for such histopathological classification, which may enhance the comparison and management of different category.

Implant Periapical Lesion: A Narrative Review

Implant periapical lesion (IPL) is an infectious-inflammatory alteration surrounding an implant apex. It is a multifactorial disease that may ultimately cause implant failure. The diagnosis of IPL is based on examination of clinical manifestations and apical radiolucency. Many etiologies have been attributed to IPL, including preexisting microbial pathology and surgical trauma. Moreover, many systems have been used to classify IPL based on different parameters. To date, non-surgical and surgical treatment, as well as removal of failed implants, have been considered to successfully manage IPL. However, prevention of IPL surpasses all modes of treatment. An increased number of IPL cases are expected as implants have become standard for tooth replacement in dentate arches. Therefore, it is necessary to understand IPL more comprehensively. Herein, an introduction to IPL, including its etiology, diagnosis, classification, treatment, and prevention, has been undertaken.

Etiology and Management of Complications Associated with Sinus Augmentation Procedures

Sinus floor elevation is a predictable procedure for vertical bone augmentation in the atrophic posterior maxilla. As with most surgical procedures, complications can be encountered during sinus floor elevation/augmentation. A clinician should have a thorough knowledge of factors that can lead to complications and possible ways to manage. Presurgical evaluation of the sinus is a prerequisite in identifying the concomitant presence of systemic disease and maxillary sinus disease that may lead to postoperative complications. Despite the best efforts, one may encounter adverse events. Complications can broadly be divided into intraoperative, acute, and chronic complications based on the timing of its occurrence. The most commonly encountered complications include membrane perforation and excessive bleeding. Evaluation of anatomic deviations and sound surgical skill is required to reduce intraoperative complications. Prevention is better than cure. It is always better to know how and when a complication might occur so that the clinician might take the necessary steps to avoid it. This article reviews the management of most commonly encountered complications and the best possible ways to manage them.

Influence of marginal bone loss on peri-implantitis: Systematic review of literature

Background

The marginal bone of dental implants is subjected to slight load modifications over time, conditioning implant survival. Objective: Perform a systematic review of the literature analyzing the factors that contribute to marginal bone loss (MBL) and the subsequent development of peri-implantitis.

Material and Methods

Bibliographic research in the databases PubMed, Medline and Scopus between 2010 and 2018 was performed. The inclusion criteria were articles published in the last 10 years and that were in English or Spanish, that were carried out on humans, that were cohort studies, that included cases and controls or that used randomized clinical trials. Exclusion criteria removed articles that contained clinical cases, case series or systematic reviews.

Results

A total of 90 articles were analyzed that examined all the factors reported in the literature, such as idiosyncratic factors, toxic habits, systemic drugs and implant characteristics (diameter, length, type surface, implant connection, implant design and type of platform at the moment of the prosthetic load). Discussion: Patient characteristics and associated pathologies must be taken into account when assessing MBL. MBL in all dental implants can be considered independent of the type of prosthetic rehabilitation and the moment of load; this was emphasized. The MBL is smaller in dental implants with rough surfaces, switch platforms and infracrestal localization, as they are of multifactorial origin.

Conclusions

All the reviewed articles maintain a common criterion regarding the concept and measurement of the MBL and highlighting the importance of radiodiagnosis for quantification. Longterm prospective studies with unified criteria are needed to reduce bias by identifying the most relevant factors in MBL.

Key words:Marginal bone loss, dental implant, peri-implantitis.

Dense cancellous bone as evidenced by a high HU value is predictive of late implant failure: a preliminary study

OBJECTIVES

The mechanism of late implant failure is unclear. This study examined the association between sclerosing cancellous bone images and the risk of late implant failures using multi-detector row computed tomography (CT) imaging data.

METHODS

We performed a case-control study. The study group consisted of consecutive patients with implant failures treated at Kyushu Dental University between 2001 and 2016. CT data for late failure of 36 implants in 16 patients were available. The study cohort consisted of 16 patients with 36 late failed implants and 28 patients with 113 successful implants.

RESULTS

The mean survival rate was 6.9 months for early implant failure, 76.6 months for late failure with marginal bone resorption, inflammation symptoms, and so-called peri-implantitis, and 95.0 months for late failure caused by implant fracture. The mean HU value for cases in the control group was 507 compared with 1231 for cases with late failure implants. Logistic regression was used for analysis. There were signs of high radiodensity of peri-implant cancellous bone when comparing adjusted radiodensity per 100 HU using CT data (OR 2.35; 95% CI 1.73-3.20; p < 0.001).

CONCLUSIONS

Within the limits of our study, the presence of high radiodensity and cancellous bone consolidation on imaging may be related to risk factors for late implant failure. Therefore, CT images of the host cancellous bone status for observation of visible sclerosis could be a useful diagnostic indicator for late implant failure.

Periapical implant lesion: A systematic review

Background

The aim of this study was to systematically review the evidence for periapical implant lesion, which makes a patient more susceptible to the periapical lesion, frequency, symptoms, signs (including radiological findings) and possible treatment options.

Material and Methods

A systematic literature review and analysis of publications included in PubMed, Embase and Cochrane; articles published until March 2016; with a populations, exposures and outcomes (PEO) search strategy was performed, focused on the issue: “In patients with periapical lesion to the implant during the osseointegration, what symptoms, signs, and changes in complementary examination manifested, for according to that stage, be intervened with the appropriate approach?”. The set criteria for inclusion were peer-reviewed articles.

Results

From a total of 212 papers identified, 36 studies were included in this systematic review, with 15461 implants evaluated and 183 periapical implant lesions. Which 8 papers included more than 5 cases and 28 included equal or less than 5 cases. Analysis of the papers revealed that periapical implant lesion is classified according to evolution stages into acute (non-suppurated and suppurated) and subacute (or suppurated-fistulized). In the acute stage and in the subacute if there is no loss of implant stability, the correct treatment approach is implant periapical surgery. In the subacute stage associated with implant mobility the implant must be removed.

Conclusions

Evidence on the subject is very limited, there are few studies with small sample, without homogeneity of criteria for diagnosing the disease and without design of scientific evidence. Currently etiology lacks consensus. The early diagnosis of periapical implant periapical lesions during the osseointegration phase and early treatment, will lead to a higher survival rate of implants treated, hence preventing the need for implant extraction.

Key words:Apical peri-implantitis, retrograde peri-implantitis, inflammatory peri-implantitis lesion.

Osteomyelitis of the Mandible after Dental Implants in an Immunocompetent Patient

Dental implants are now broadly used to replace missing teeth, and the presence of infectious complications is rising. Dental implant therapy as a local risk factor for the onset of osteomyelitis and its management have not been widely explored. Here, we report an unusual case of mandibular suppurative osteomyelitis caused by Streptococcus intermedius in a healthy and immunocompetent patient secondary to mandibular implants. We describe how surgery combined with systemic application of antibiotics allowed conservation of the dental implants in the mandibular bone, discuss the probable source of contamination, and present the follow-up of the osteomyelitis.

Assessment of Intraobserver and Interobserver Agreement of a New Classification System for Retrograde Periimplantitis

BACKGROUND

Retrograde periimplantitis (RPI) is the inflammatory disease that affects the apical part of an osseointegrated implant while the coronal portion of the implant sustains a normal bone-to-implant interface. The aim of the current study was to assess the intraexaminer and interexaminer reliability of a proposed new classification system for RPI.

MATERIALS AND METHODS

After thorough electronic literature search, 56 intraoral periapical radiographs (IOPA) of implants with RPI were collected and were classified by 2 independent reviewers as per the new classification system into one of the 3-mild, moderate, and advanced-classes based on the amount of bone loss from the apex of the implant to the most coronal part as a percentage of the total implant length. The IOPAs were assessed twice by the same examiners and both were blinded to each other's observations.

RESULTS

The intraobserver agreement ranged from 0.85 to 0.91, which falls under the category of almost perfect agreement. The interexaminer agreement was found to be 0.83, also considered as almost perfect agreement.

CONCLUSION

The proposed classification shows good intraexaminer and interexaminer reliability and can be used for treatment planning and prognosis in cases of RPI.

A Radiographic Classification for Retrograde Peri-implantitis

BACKGROUND

Retrograde peri-implantitis (RPI) is an inflammatory disease that affects the apical part of an osseointegrated implant, while the coronal portion of the implant sustains a normal bone-to-implant interface. It is a diagnostic and therapeutic dilemma for implantologists. There is lack of a standard classification system and a definite treatment algorithm for the same. This article aims to introduce a classification system for RPI based on the radiographic amount of bone loss around an implant apex.

MATERIALS AND METHODS

A search of PubMed database was conducted with the keywords "retrograde peri-implantitis" and "implant periapical lesion." Preoperative intraoral periapical (IOPA) radiographs of implants with RPI in case reports/case series were compiled. A total of 54 lOPAs from 36 articles were compiled and were assessed.

RESULTS

Three different classes were proposed. The amount of bone loss from the apex of the implant to the most coronal part of radiolucency was calculated as a percentage of the total implant length and classified into one of the three classes: Mild, moderate, and advanced. Treatment options and prognosis have been suggested for each class.

CONCLUSION

The proposed classification may allow for an easy and reproducible radiographic assessment of the RPI lesion and may serve as a guideline to prognosis and treatment planning.

Diagnostic Accuracy of CBCT with Different Voxel Sizes and Intraoral Digital Radiography for Detection of Periapical Bone Lesions: An Ex-Vivo Study

OBJECTIVES

This study sought to assess the diagnostic accuracy of cone beam computed tomography (CBCT) with different voxel sizes and intraoral digital radiography with photostimulable phosphor (PSP) plate for detection of periapical (PA) bone lesions.

MATERIALS AND METHODS

In this ex vivo diagnostic study, one-millimeter defects were created in the alveolar sockets of 15 bone blocks, each with two posterior teeth. A no-defect control group was also included. Digital PA radiographs with PSP plates and CBCT scans with 200, 250 and 300μ voxel sizes were obtained. Four observers evaluated the possibility of lesion detection using a 5-point scale. Sensitivity, specificity, positive predictive value (PPV) and negative predicative value (NPV) were analyzed using one-way ANOVA and Tamhane's post hoc test. Kappa and weighted kappa statistics were applied to assess intraobserver and interobserver agreements.

RESULTS

Cochrane Q test showed no significant difference between PSP and CBCT imaging modalities in terms of kappa and weighted kappa statistics (P=0.675). The complete sensitivity and complete NPV for 200 and 250 μ voxel sizes were higher than those of 300 μ voxel size and digital radiography (P<0.001). No significant difference was noted in other parameters among other imaging modalities (P=0.403).

CONCLUSIONS

The results showed that high-resolution CBCT scans had higher diagnostic accuracy than PSP digital radiography for detection of artificially created PA bone lesions. Voxel size (field of view) must be taken into account to minimize patient radiation dose.