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Background
Overall certainty of the evidence The certainty of evidence is graded as moderate based on the lack of direct comparisons between surgical and non-surgical therapy of peri- implantitis.
Intervention
Reconstructive procedures aim to regenerate the bony defect, achieve re-osseointegration and limit peri-implant soft tissue recession (Jepsen et al., 2019). Reconstructive therapy of peri-implant bone defects includes the use of bone grafts, bone replacement grafts, bar- rier membranes, bioactive agents (growth factors, autologous platelet concentrates and amelogenin) or combinations thereof.
From evidence to recommendation — additional considerations
Acceptability PROMs were reported in two studies, only. Limited data suggest a high degree of patient satisfaction at 1 year after surgical therapy. Adverse events reported in three studies were mostly related to the use of systemic antibiotics.
Available evidence
Feasibility Related procedures are clinically demanding.
Number and design of included studies Seven RCTs assessed the efficacy of reconstructive surgery (total of 200 implants in 194 patients) compared with access flap surgery (total of 188 implants in 184 patients) (Donos et al., 2023). Different types of reconstructive surgeries were documented, including the use of titanium granules, amelogenin, deproteinized bovine bone mineral (DBBM or DBBM graft with 10% collagen) alone or combined with a native bilayer collagen membrane, or a beta-tricalcium phosphate graft formulated with prolonged release of local doxycycline. Risk of bias Based on RoB 2, there was concern for four studies in one domain (predominantly due to bias in measurement of the outcome), while three studies were considered at high risk of bias, mainly due to the combination of missing outcomes and bias in selection of the reported results. Effect sizes and their clinical relevance Meta-analysis (4 studies; 262 patients and 272 implants) showed an estimated MD in PD changes between access flap surgery and recon- structive surgery of 0.39 (95% CI [ 1.16; 0.24]; p = .325, I 2 = 66.4%) at 12 months. No evidence of small-study effects was detected. Among the five studies that reported on BOP changes at 12 months, one study showed a statistically significant improvement for reconstructive therapy as compared with access flap surgery. No differences were indicated in relation to the change in SOP. At 12 months, implant survival was similar between the two treatment procedures, ranging from 85.7% to 100% for access flap and from 95% to 100% for reconstructive therapy. Meta-analysis for changes in radiographic mean bone levels (4 studies; 262 patients and 272 implants) showed a statistically significant benefit of reconstruc- tive compared with access flap surgery of 0.75 mm (95% CI [ 1.39; 0.11]; p = .022; I 2 = 83.4%). The CI is presented with negative values, since in the original analyses positive values indicated more gain for access flap and negative for reconstructive procedures. Irrespective of the surgical approach and biomaterial employed, resolution of peri-implantitis is unpredictable and a significant dif- ference between the two treatment approaches was not consis- tently shown.
Ethical considerations Some decontamination procedures evaluated in the studies included have not been tested for safety. Economic considerations Health economic parameters were not evaluated in the identified studies. In general, surgical therapy of peri-implantitis is a costly pro- cedure. Some decontamination procedures may generate additional costs in the absence of documented benefit. Legal considerations Some decontamination procedures evaluated in the studies included have not been tested for safety and are considered off-label.
8.3
| Management of peri-implant osseous defects
using reconstructive approaches
R8.7. Do reconstructive procedures used in the management of osseous defects (e.g., bone substitute materials) as part of surgical treatment of peri- implantitis result in superior outcomes when compared with access flap alone?
PICOS question addressed by an SR
R8.7: Evidence-based recommendation In the surgical management of osseous defects in peri-implantitis patients, access flap with or without reconstructive procedures may be considered ; no evidence demonstrating superiority of any specific surgical technique was identified . Supporting literature (Donos et al., 2023) Quality of evidence Low Grade of recommendation GradeO $ (need for further research) Strength of consensus Consensus (19.0% of the group abstained due to potential CoI)
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