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Current Concepts in the treatment of Peri-Implantitis

A narrative literature review with special emphasis on the work of Jan Derks

Abstract

Peri-implantitis represents one of the most relevant biological complications in modem implant dentistry and is characterized by a biofilm-induced inflammatory process associated With progressive peri-implant bone loss. Despite high implant survival rates, long-term control of peri-implant diseases remains challenging. The aim of this narrative literature review is to summarize evidence-based treatment strategies for peri-implantitis, With particular emphasis on the epidemiological, clinical, and therapeutic contributions of Jan Derks. Non-surgical and surgical treatment modalities, defect morphology, prognostic factors, long-term outcomes, and clinical implications for daily practice are discussed.

1. Introduction

With the increasing use of dental implants, peri-implantitis has become a major biological complication of clinical relevance. In contrast to peri-implant mucositis, peri-implantitis is associated With irreversible bone loss and limited therapeutic predictability. The work of Jan Derks has substantially contributed to the understanding of disease prevalence, progression patterns, and treatment outcomes, forming an important basis for contemporary treatment concepts [2 – 4].

2. Disease Course and Progression

Epidemiological and longitudinal studies from Swedish cohorts have demonstrated that peri-implantitis often develops early after implant placement and follows a non-linear pattern of progression. Periods of relative stability may be interrupted by episodes of accelerated bone loss, emphasizing the importance of early diagnosis, timely intervention, and Close monitoring [3]. These findings have direct implications for treatment planning and maintenance strategies.

3. Treatment of Peri-implantitis – a Stepwise Therapeutic Concept

The management of peri-implantitis requires a Structured, indication-based approach. Key determinants for treatment selection include the severity of inflammation, peri-implant defect morphology, patient-related risk factors, and prosthetic and aesthetic considerations. In accordance with current evidence, peri-implantitis therapy can be divided into four sequential treatment steps [1,4].

3.1 Non-surgical Therapy (Step 1)

Non-surgical therapy represents the initial phase of treatment and primarily aims to reduce inflammatory activity and bacterial Ioad. This includes mechanical decontamination of the implant surface using implant-friendly instruments, optionally supplemented by air-polishing procedures. In addition, structured oral hygiene instruction, removal of iatrogenic factors such as residual cement or overcontoured restorations, and management of systemic risk factors are essential components of this step [5 – 7].

However, systematic reviews indicate that non-surgical therapy alone has limited efficacy in cases of established peri-implantitis with bone loss. Although inflammatory parameters may improve, stable disease resolution is rarely achieved. Consequently, this treatment step mainly serves as preparation for further surgical intervention [5,6].

3.2 Surgical Access Therapy (Step 2)

If inflammation persists following non-surgical therapy or deep peri-implant pockets are present at baseline, surgical access therapy is indicated. The objectives are direct visualization of the defect, complete removal of granulation tissue, and thorough decontamination of the implant surface. Surgical access therapy constitutes the foundation for all subsequent surgical treatment approaches [1,5].

Clinical studies report improvements in probing depths and inflammatory parameters; however, predictable bone gain is generally not achieved. Therefore, access flap surgery is usually not considered definitive treatment but rather part of a comprehensive surgical strategy [5,8].

3.3 Resective Surgical Therapy (Step 3)

Resective surgical approaches aim to eliminate pathological peri-implant pockets and establish anatomically maintainable conditions. Typical procedures include osteoplasty or ostectomy, apically positioned flaps, and, where necessary, smoothing of exposed implant surfaces. The primary goal is functional disease control rather than regeneration of lost bone [8,9].

This approach is particularly indicated in cases of supra-osseous or horizontal defects and in non-aesthetic regions. While the likelihood of pocket elimination is high, resective therapy is frequently associated With pronounced soft tissue recession, which limits its use in aesthetically demanding areas [9].

3.4 Reconstructive or Regenerative Surgical Therapy (Step 4)

Reconstructive treatment strategies aim to restore intra-osseous or combined peri-implant defects to improve peri-implant bone Ievels while minimizing soft tissue recession. Following surgical access and thorough implant surface decontamination, bone substitute materials may be applied, sometimes in combination with barrier membranes or biological adjuncts [10,11].

A major contribution to the evidence base for reconstructive peri-implantitis therapy stems from multicenter randomized controlled clinical trials conducted by Derks and colleagues. These studies demonstrated significant improvements in clinical parameters and radiographic outcomes following reconstructive surgery [4]. However, the additional benefit of specific biomaterials is not consistently demonstrated and appears to depend strongly on defect morphology, surgical protocol, and patient-related factors [10,11].

4. Treatment Algorithm for Peri-implantitis

  • Diagnosis and Risk Assessment
    • → Bleeding and/or suppuration on probing
    • → Probing pocket depths and radiographic bone loss
    • → Evaluation of patient-related risk factors
  • Step I: Non-surgical therapy
    • → Re-evaluation after 6 – 12 weeks
  • Persistent inflammation / PPD 5 ≥ 6 mm
    • → Surgical therapy indicated
  • Step 2: Surgical access therapy
    Assessment of defect morphology:
    • Supra-osseous / horizontal defects → Resective surgical therapy (Step 3)
    • Intra-osseous or combined defects, aesthetic relevance → Reconstructive surgical therapy (Step 4)
  • Long-term management:
    • → Supportive implant therapy at 3 – 6 month intervals [1, 13,14]

5. Conclusions

The treatment of peri-implantitis requires a structured, stepwise approach. While non-surgical measures are essential for initial inflammation control, they are insufficient in cases of established bone loss. Surgical interventions therefore Play a central role in disease management. The work of Jan Derks highlights that reconstructive surgical approaches may provide clinically meaningful improvements in appropriately selected defects, but long-term stability can only be achieved through consistent supportive implant therapy.

References

  • 1. Herrera D, Berglundh T, Schwarz F, et al. Prevention and treatment of peri-implant diseases: The EFP S3 Ievel clinical practice guideline. Journal of Clinical Periodontology. 2023;50(Suppl 26):4–76. doi: 10.1111/jpce.13703
  • 2. Derks J, Schaller D, Håkansson J, Wennström JL, Tomasi C, Berglundh T. Effectiveness of implant therapy analyzed in a Swedish population: prevalence of peri-implantitis and risk indicators. Journal of Dental Research. 2016;95(1):43 – 49. doi: 10.1177/0022034515608832
  • 3. Derks J, Tomasi C, Berglundh T. Peri-implantitis – onset and pattern of progression. Journal of ClinicaI Periodontology. 2016;43(4):383—388. doi: 10.1111/jpce.12535
  • 4. Derks J, Carcuac O, Abrahamsson I, et al. Reconstructive surgical therapy ofperi-implantitis: a multicenter randomized controlled clinical trial. Journal of Clinical Periodontology. 2022;49(9):845 – 856. doi: 10.1111/jpce.13664

Nicht-chirurgische Therapie / Adjunktive Maßnahmen

  • 5. Schwarz F, Schmucker A, Becker J. Efficacy of alternative or adjunctive measures to conventional treatment of peri-implant mucositis and peri-implantitis: a systematic review and meta-analysis. International Journal of Implant Dentistry. 2015; 1:22. doi:10.1186/s40729-015-0023-1
  • 6. Suárez-Lopez del Amo F, Yu S-H, Wang H-L. Non-surgical therapy for peri-implant diseases: a systematic review. Journal of Oral and Maxillofacial Research. 2016;7(3):e13. doi:10.5037/jomr.2016.7313
  • 7. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic Study. Joumal of Periodontology. 2009;80(9): 1388—1392. doi: 10.1902/jop.2009.090115

Chirurgische Therapie - resektiv

  • 8. Schwarz F, Sahm N, Iglhaut G, Becker J. Impact of the method of surface decontamination on the clinical outcome following surgical regenerative treatment of peri-implantitis. Journal of Clinical Periodontology. 2011 ;38(3):276 – 284. doi: 10.1111/j.1600-051X.2010.01667.x
  • 9. Romeo E, Ghisolfi M, Murgolo N, Chiapasco M, Lops D, Vogel G. Therapy of peri-implantitis with resective surgery: a 3-year clinical trial on rough screw-shaped oral implants. Part I: clinical outcome. Clinical Oral Implants Research. 2005; 16(1):9 – 18. doi: 10.1111/j.1600-0501.2004.01065.x

Chirurgische Therapie — rekonstruktiv I regenerativ

  • 10. Tomasi C, Regidor E, Ortiz-Vig6n A, Derks J, Schaller D. Efficacy of reconstructive surgical therapy at peri-implantitis-related bone defects: a systematic review and meta-analysis. Journal of Clinical Periodontology. 2019;46(Suppl 21):340 – 356. doi: 10.1111/jcpe.13070
  • 11. Schwarz F, Jepsen S, Herten M, et al. Influence of defect configuration on the clinical outcome following surgical regenerative therapy of peri-implantitis. Journal of Clinical Periodontology. 2010;37(5):449 – 455. doi: 10.1111/j.1600.051X.2010.01548.x

Langzeitoutcomes & Rezidivrisiko

  • 12. Carcuac O, Abrahamsson I, Albouy J-P, Linder E, Larsson L, Berglundh T. Experimental peri-implantitis and treatment. A histological Study in dogs. Clinical Oral Implants Research. 2013;24(4):363 – 371. doi:10.1111/j.1600-0501.2012.02429.x
  • 13. Carcuac O, Derks J, Abrahamsson I, Wennström JL, Berglundh T. Risk for recurrence of disease following surgical therapy of peri-implantitis. Journal of Clinical Periodontology. 2020;47(2):273 – 284. doi:10.1111/jcpe. 13216
  • 14. Romandini M, Lima C, Pedrinaci I, Araoz A, Soldini MC, Sanz M. Clinical outcomes and prognostic factors of surgical treatment of peri- implantitis: a systematic review and meta-analysis. Clinical Oral Implant s Research. 2024;35(1):3 – 23. doi:10.1111/clr.14129