In the two-stage surgical technique for placement of endosseous dental implants, the implant is submerged underneath the mucosa for the duration of the osseointegration period. The two-stage method relies upon primary closure of the wound and adaptation of bone to the implant in a sterile and stress-free environment. However, spontaneous early exposure of dental implants, between Stage I and Stage II surgery, is not an uncommon complication. In a 15-year study of osseointegrated implants, Adell et al 1 found an occurrence of 4.6% early perforations of the treated patients despite a careful surgical protocol and postsurgical care.
Bacterial colonization can occur during this osseointegration period when a direct communication between the implant surface and the oral environment is established. Early perforation and partial exposure of the coverscrew is a focus for plaque accumulation (Fig. 1) which, if left untreated, may result in inflammation, damage to the peri-mucosa, and possible bone loss. 2–4 Thus, early detection of these exposures becomes very important in terms of prevention.
In this article we propose methods of diagnoses and an easy-to-use clinical classification system of coverscrews’ spontaneous early exposures of submerged implants. In addition, treatment modalities to prevent or intercept mucositis or periimplantitis during Stage I and Stage II surgeries will be presented according to the proposed classification.
Tal, 3 in 1999, first clinically described and classified spontaneous early exposure of submerged implants: Class 0: the mucosa covering the implant is intact. Class 1: a breach in the mucosa covering the implant is observed. Coverscrew can be detected by a periodontal probe. Class 2: The mucosa above the coverscrew is fenestrated. Coverscrew is visible. The borders of the perforation’s aperture do not reach or overlap the borders of the coverscrew at any point. Class 3: Coverscrew is visible. In some parts, the borders of the perforation’s aperture overlap the borders of the coverscrew. Class 4: Coverscrew is completely exposed.
Considering that spontaneous early exposures are complications that can lead to mucositis or periimplantitis, we propose an easy-to-use classification for spontaneous early exposure of submerged implants based on diagnostic methods and treatment modalities to prevent or intercept such complications. Class I—Coverscrew spontaneous early partial exposure. This means a communication between the coverscrew and oral cavity, with a fenestrated mucosa still partially covering the coverscrew. Clinically we can observe six types of partial fenestrations that can be considered Class I (Fig. 2). Class II—Coverscrew spontaneous early total exposure. This means that the fenestration reveals the coverscrew completely.
Subdivisions are proposed based on clinical signs of healthy, inflammation, and suppuration:
A. No signs of inflammation. Mucosa texture, volume, and color are within the normal limits of health. No purulent exudate is observed.
B. No signs of inflammation with suppuration. Mucosa texture, volume, and color are within the normal limits of health, however, purulent exudate is present.
C. Signs of inflammation. Mucosa texture and/or color are altered. Edematous mucosa and/or pain may be present. However, visually or upon palpation, no purulent exudate is observed.
D. Signs of inflammation with suppuration. Fenestrated mucosa presents signs of inflammation, and, visually or upon palpation, purulent exudate is observed.
Examples of spontaneous early exposure of submerged implants are seen in Figs. 3 to 6.
Methods of Diagnosis of Spontaneous Early Exposure
Providing the most appropriate treatment requires making an accurate diagnosis. Keeping up-to-date with current information, having a system for proper patient evaluation, and the knowledge to help make treatment decisions, improve the opportunity for successful outcomes. 5
To make a diagnosis of an early spontaneous exposure of coverscrews during the initial healing phase of submerged dental implants, several aspects have to be considered. First, patient complaints most often launch the information needed to reach a diagnosis. Attention to what a patient describes is always helpful. In the case of a perforated mucosa around implants, the patient definitely will describe a change, especially if it achieves classification II. The patient may report an edematous and/or painful mucosa before professional examination. Another important aspect is that a complete professional examination, every other week during the period of initial healing, must be performed. A clinical examination consists of looking for mucosa fenestration using air, probe, and mirror (especially for lingual perforations). In addition, palpation is always needed to observe if purulent exudate is present. Many times the fenestration is clinically visible only when purulent exudate comes out from the mucosal orifices after palpation (Fig. 4a). Radiographs are also recommended to identify loose coverscrews and premature bone loss. Prostheses, especially removable appliances, need to be checked to evaluate for the presence of trauma.
Here we propose treatment modalities that can be used to prevent or intercept mucositis or periimplantitis when spontaneous early coverscrew exposure is diagnosed. Spontaneous early exposure of submerged implants classification and treatment modalities are shown in Table 1.
Treatment Modality 1 (TM1) includes cover screw professional cleaning, oral hygiene instructions reinforcement, rinses with chlorhexidine digluconate 0.12%, and shorten recall periods. If plaque and/or calculus is detected, the coverscrew should be mechanically cleaned using specific curettes, abrasive air, rubber cup, and polishing paste. Patient oral hygiene practices should be checked, and instructions for a more effective oral hygiene routine should be emphasized. Rinses or local application of chlorhexidine digluconate 0.12% twice daily must be prescribed. Another important aspect is that a complete professional examination, every other week during the period of initial healing, must be performed.
In the presence of signs of inflammation, which include alteration of mucosa volume, texture and/or color, bleeding or pain, and purulent exudates, radiographs will be indicated to evaluate periimplant bone morphology.
Treatment Modality 2 (TM2) includes microorganisms identification and antibiotic therapy. In the presence of purulent exudates, specific microbial information is indispensable. Microbiological samples must be collected to identify the putative pathogens (Fig. 7A). If the patient presents a localized periimplant problem, a topic antibiotic therapy can be considered. However, if the patient presents other areas of periimplant and/or periodontal diseases, a systemic antibiotic, according to microbiological test findings, should be administered.
Treatment Modality 3 (TM3) includes coverscrew surgical exposure and adaptation of a healing abutment. The mucosa borders overlaying the coverscrew creates a bacterial focus resembling pericoronitis that needs to be eliminated. To avoid the mucosa regrowth and facilitate patient oral hygiene, a healing abutment should be placed over the implant (Fig. 7B).
Treatment Modality 4 (TM4) includes periimplantitis treatment. If bone destruction is radiographically detected, surgical intervention to correct tissue morphology or to apply guided bone regeneration techniques is necessary.
This article presents methods of diagnoses and an easy-to-use clinical classification system of coverscrews of submerged implants that have spontaneous early exposure. In addition, treatment modalities, to prevent or intercept mucositis or periimplantitis during Stage I and Stage II surgeries, were considered according to the proposed classification.
The importance of the understanding and of making an early diagnosis of a mucosal fenestration during the initial healing phase of submerged dental implants is based on the existence of an “intraoral” transmission of bacteria from one niche to another, which has been reported in the literature. 6 There is a consensus that present periodontal diagnostic procedures based on traditional signs of gingival inflammation, probing depths, and attachment loss remain the foundation upon which periodontal diagnoses are made. 7 These procedures share a number of strengths. They are relatively noninvasive, easy to use, and cost-effective. 7 Because probing is not a routine examination method around dental implants, visual signs of mucosal alterations appear to place an important role on the diagnoses of disease. In addition, there is abundant evidence in the literature suggesting that suppuration is associated with disease activity. 8 Also, patient complaints and regular professional examinations during the initial healing phase are important tools to achieve diagnoses of spontaneous early coverscrew exposures.
Tal reported that 51 (13.7%) of 372 implants presented spontaneous early exposure. 3 Toljanic et al reported early exposure at the time of the Stage II procedure in 14 implants (5%) in 7 patients (14%) of a total of 275 implants placed. 4 The exposure of an implant through the mucosa as noted clinically after Stage I surgery, but before Stage II surgery, appeared qualitatively to be associated with an increased incidence in crestal bone loss. 2 Depending upon the quality of bone, 2 to 8 months are needed for the osseointegration period. 9 Nevertheless, every-other-week visits are advisable. If complications are observed, treatment must be initiated.
The School of Dentistry of University of Bern, Switzerland developed an approach to implant maintenance and therapy of periimplantitis called Cumulative Interceptative Suppurative Therapy (CIST). 10 The basis for this approach is a regular recall of the implant patients and the repeated assessment of the following key parameters around each implant: presence of plaque, the bleeding tendency of the periimplant tissues, suppuration, presence of periimplant pockets, and radiological evidence of bone loss. The goal of this cumulative treatment system is to intercept periimplant tissue destruction as early as possible and to avoid explanation because of loss of osseointegration. 10 However, the CIST protocol was not designed to be applied during the period between first- and second-stage surgeries in cases of spontaneous early exposure of submerged implants.
When exposure was detected or observed, Tal instructed his patients to clean the exposed site by gently rubbing the mucosa with gauze soaked in 0.2% chlorhexidine solution twice daily. 3 According to Adell et al, in a 15-year study of osseointegrated dental implants, any communication with oral cavity observed during the first 6 weeks postoperative should be treated by excision of the perforated site, flap mobilization resuturing, and proper adjustment of the prostheses. 1 We suggest that implants presenting early spontaneous exposure (Class I) should be completely surgically exposed as early as possible to prevent or to treat mucositis. The coverscrew must be removed and the healing abutment placed, allowing for better hygiene. In the presence of purulent exudates, microbiological samples must be collected to identify the putative pathogens. If the patient presents a localized periimplant problem, a topic antibiotic therapy can be considered. However, if the patient presents other areas of periimplant and/or periodontal diseases, a systemic antibiotic, according to microbiological test findings, should be administered.
The epithelial components around implants seem to be consistent with epithelial components around teeth, whereas the connective tissue, although having a similar composition, has a dramatically different spacial orientation. In addition, the space between the coverscrew and the overlying mucosa is an ideal area for the accumulation of food debris and bacterial growth. Also, these areas are very difficult for patient oral hygiene. Plaque formation during the postoperative period after implant placement may result in a compromised epithelial attachment to the implant surface. 11–12 Subsequently, there may be continued plaque accumulation, increased mucosal inflammation, and deeper probing depths around implants. 13
We have been observing that when the fenestration is minimal and almost clinically invisible, implants are the most susceptible to present purulent exudate. Our previous study 14 comparing submerged and exposed dental implants in 10 patients showed more crestal bone loss around exposed implants than submerged implants. Prevotella sp., Streptococcus beta-hemoliticus, and Fusobacterium sp. were the microorganisms identified in most of the exposed sites.
In our private practice, no implant has been lost after loading for the past 4 years of follow-up. However, the implants which have been lost, were during the first- to second-stage surgeries. These clinical observations brought us to develop an easy-to-use classification—Class I and II with subdivisions of A, B, C, and D of spontaneous early exposure of submerged implants. This classification brings us to treatment modalities to prevent, or intercept, mucositis and/or periimplantitis.
1. Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981; 10: 387–416.
2. Block MS, Kent JN. Factors associated with soft- and hard-tissue compromise of endosseous implants. J Oral Maxillofac Surg. 1990; 48: 1153–1160.
3. Tal H. Spontaneous early exposure
of submerged implants: I. Classification and clinical observations. J Periodontol. 1999; 70: 213–219.
4. Toljanic JA, Banakis ML, Willes LA, et al. Soft tissue exposure
of endosseous implants between stage I and II surgery as a potential indicator of early crestal bone loss. Int J Oral Maxillofac Implants. 1999; 14: 436–441.
5. Sackett DL, Haynes RB, Guyatt GH, et al. Clinical Epidemiology: A Basis Science for Clinical Medicine, 2nd
ed. Boston: Little Brown, 1991: 36–39.
6. Quirynen M, Papajoannou W, van Steenberghe D. Intraoral transmission and the colonization of oral hard surfaces. J Periodontol. 1996; 67: 986–993.
7. Armitage CG. Periodontal diseases: Diagnosis. Ann Periodontol. 1996; 1: 37–215.
8. Lamster IB, Oshrain RL, Harper DS, et al. Enzyme activity in crevicular fluid for detection and prediction of clinical attachment loss in patients with chronic adult periodontitis: 6-month results. J Periodontol. 1988; 59: 516–523.
9. Misch CE. Bone density: A key determinant for clinical success. In: Contemporary Implant Dentistry, 2nd
ed. St. Louis: Mosby, 1998: 109–118.
10. Mombelli A. Prevention and therapy of periimplant infections. In: Lang, NP, Karring T, Lindhe J, eds. Proceedings on the 3rd European Workshop on Periodontology
. London: Quintessence Publishing Company, 1999: 281–303.
11. Koth DL, McKinney RV, Steflik DE, et al. The single crystal Al2O3 implant: The results of three years of human clinical trials. Implantologist. 1986; 4: 47–53.
12. Berglundh T, Lindhe J, Marinello C, et al. Soft tissue reaction to de novo plaque formation on implants and teeth. An experimental study in the dog. Clin Oral Implants Res. 1992; 3: 1–8.
13. Ericsson I, Lekholm U, Branemark P-I, et al. A clinical evaluation of fixed-bridge restorations supported by the combination of teeth and osseointegrated titanium implants. J Clin Periodontol. 1986; 13: 307–312.
14. Barboza EP, Caúla AL, Carvalho WR. Crestal bone loss around submerged and exposed unloaded dental implants: A radiographic and microbiological descriptive study. Implant Dent. 2002; 11: 162–169.
The authors have no financial interest in any company or any of the products mentioned in this article.
Abstract Translations [German, Spanish, Portuguese, Japanese]
AUTOR(EN): Eliane P. Barboza, CD, MScD, DScD* und Andre Luis Caula, CD, MScD**. *Vorsitzender, Brasilianisches Institut für Parodontologie und Professor für Parodontologie, Staatliche Universität Fluminense, Rio de Janeiro, Brasilien. ** stellvertretender Vorsitzender, Brasilianisches Institut für Parodontologie und zahnärztlicher Leiter, Staatliche Feuerwehr Rio de Janeiro, Brasilien. Shriftverkehr: Eliane P. Barboza, CD, MScD, DScD, Av Pres Wilson, 165 Sala 810, Rio de Janeiro 20030 - 020, BRASILIEN. Fax: # 55 21 22206706. eMail:[email protected]
ZUSSAMENFASSUNG: Die vorzeitige Spontanexposition von Implantaten kann zu Beginn der Heilungsphase zu ernsthaften Komplikationen führen. An diesen frühzeitig entstandenen Perforationen und Teilfreilegungen der Deckschrauben lagert sich vermehrt Zahnbelag an, der unbehandelt zu Entzündungen, Schädigungen der um das Implantat liegenden Schleimhaut und letztendlich sogar zu Knochengewebsverlust führen kann. Aufgrund ihrer manchmal minimalen Größe bleiben solche Expositionen selbst bei klinischen Untersuchungen unentdeckt. Die vorliegende Arbeit beschäftigt sich daher mit Diagnosemöglichkeiten bei Schleimhautdefekten, die um versenkte Implantate herum auftreten. Außerdem wird innerhalb des Artikels der Vorschlag einer gut nachvollziehbaren und daher praxisnahen Klassifizierung der vorzeitigen Spontanfreilegung unterbreitet. Des Weiteren erfolgen Hinweise bezüglich Behandlungsvarianten, wie einer Schleimhautentzündung bei Auftreten frühzeitiger Freilegungen während der ersten Heilungsphase vorzubeugen bzw. wie sie zu unterbinden ist.
SCHLÜSSELWÖRTER: Zahnimplantate, Schleimhautentzündung, Entzündung des in der Implantatumgebung befindlichen Gewebes, Exposition
AUTOR(ES): Eliane P. Barboza, CD, MScD, DScD* y André Luis Cáula, CD, MScD**. *Presidente, Instituto Brasileño de Periodontología y Profesor de Periodontología, Universidad Federal de Fluminense (UFF), Río de Janeiro, Brasil. **Vicepresidente, Instituto Brasileño de Periodontología y Teniente Primero Dentista, Departamento de Bomberos del Estado de Río de Janeiro, Río de Janeiro, Brasil. Correspondencia a: Eliane P. Barboza, CD, MScD, DScD, Av. Pres. Wilson 165, Sala 810, Río de Janeiro 20030-020, BRASIL. Fax: 55 21 22206706. Correo electrónico:[email protected]
ABSTRACTO: La exposición inicial espontánea de los implantes puede convertirse en una seria complicación durante la fase inicial de la curación. Estas perforaciones iniciales y la exposición parcial de los tornillos son un lugar para la acumulación de sarro que, la cual, si no se la trata, podría resultar en la inflamación, daño a la mucosa periimplante y posible pérdida del hueso. Algunas veces, estas exposiciones son tan pequeñas que no son clínicamente visible. Este artículo presenta métodos de diagnóstico de la mucosa perforada alrededor de implantes sumergidos. Además, se propone una clasificación fácil de usar de la exposición inicial espontánea. Se sugieren modalidades del tratamiento para prevenir o interceptar la mucositis durante la fase inicial de la curación, cuando ocurren las exposiciones iniciales.
PALABRAS CLAVES: Implantes dentales, mucositis, periimplantitis, exposición
AUTOR(ES): Eliane P. Barboza, CD, MScD, DScD* e André Luis Caúla, CD, MScD**. *Presidente, Instituto Brasileiro de Periodontologia e Professora de Periodontologia, Universidade Federal Fluminense (UFF), Rio de Janeiro, Brasil. **Vice-presidente, Instituto Brasileiro de Periodontologia e Primeiro-Tentente Dentista, Corpo de Bombeiros do Estado do Rio de Janeiro, Rio de Janeiro, Brasil. Correspondências devem ser enviadas a: Eliane P. Barboza, CD, MScD, DScD, Av. Pres. Wilson, 165, Sala 810, Rio de Janeiro 20030-020, BRASIL. Fax: 55 21 2220-6706; e-mail:[email protected]
SINOPSE: a exposição espontânea prematura de implantes pode transformar-se em uma grave complicação durante a fase inicial de cicatrização. Tais perfurações prematuras e exposição parcial dos parafusos de proteção representam focos para o acúmulo de placas que, caso não sejam tratadas, poderão resultar em inflamação, lesões na mucosa periimplantária e em possível perda óssea. Em algumas situações, tais exposições são tão pequenas que se tornam clinicamente invisíveis. Este artigo apresenta métodos de diagnósticos de mucosa perfurada ao redor de implantes encobertos. Além disso, há a proposta de uma classificação de fácil utilização da exposição espontânea prematura. São sugeridas modalidades de tratamento a fim de evitar ou interceptar a mucosite durante a fase inicial de cicatrização, em que ocorrem exposições prematuras.
PALAVRAS-CHAVES: implantes odontológicos, mucosite, periimplantite, exposição