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Fig. 3.16. Peri‐implantitis leading to bone loss (crater‐like defect).

Table 3.5. Peri‐implant mucositis versus peri‐implantitis

Clinical parameter	Peri‐implant mucositis	Peri‐implantitis
Increased probing depth	+/−	+
BOP	+	+
Suppuration	+/−	+
Implant mobility	−	+/−
Radiographic bone loss	−	+

Fig. 3.17. Periapical radiograph showing bone loss due to peri‐implantitis.

A clear distinction needs to be made between increased probing depths around a dental implant and an established diagnosis of peri‐implantitis. Often bone levels around the implant may be ideal; however, a soft tissue pannus formation, in the form of a gingival pseudo‐pocket, may lead inexperienced clinicians to diagnosis a case of peri‐implantitis [36]. Although this excessive pseudo‐pocket is not ideal and can lead to oral hygiene issues with eventual bone loss, this is not an inevitable consequence. With meticulous oral hygiene maintenance and close follow‐up, this region can often be maintained without any untoward effects. In certain circumstances, gingivectomy may be required for excessive soft tissue, but careful attention must be paid to not affect the esthetic outcomes of the soft tissues, especially in the anterior esthetic zone. Once a diagnosis of peri‐implantitis has been established, the clinician must control the contributing factors, assess the presence of keratinized tissue, and evaluate the implant surface, implant location, restorative issues, and the presence of parafunctional habits [37]. Since these factors have been discussed previously, the discussion will focus on the surgical management of the implant with localized bone loss and inflammation with the understanding that other contributing factors have been addressed in order to optimize the outcome. Many of the initial stages of peri‐implantitis can be managed similar to periodontal disease. Nonsurgical peri‐implant debridement includes chemical and mechanical debridement. Chemical debridement with various topical agents such as chlorhexidine, citric acid, hydrogen peroxide, and tetracycline can be used. Mechanical debridement with implant scalers, titanium brushes, and lasers can be used. These techniques should be combined with patient education on the use of meticulous oral hygiene to help decrease peri‐implant soft tissue inflammation allowing for increased tissue adherence (soft tissue seal) around the implant fixture [38]. This increased tissue tone decreases bacterial migration along the implant surface and can prevent further infection and bone loss. More advanced cases of peri‐implantitis, with up to 50% bone loss, must be assessed regarding a guarded long‐term implant prognosis. If the implant is deemed salvageable, this will require open surgical debridement, bone grafting with guided tissue membrane regeneration, and temporary removal of the existing restoration [39]. Once appropriate bone and soft tissue healing has occurred, with evidence of adequate osseous regeneration around the implant, the implant may be uncovered and prosthetically restored. Peri‐implantitis that has progressed to greater than 50% bone loss, implant mobility, and recurring infections often necessitate implant removal and bone grafting with delayed implant replacement and restoration (Algorithm 3.7).