Potential Risk Factors

and their association with Peri-Implantitis

This checklist summarizes the potential risk factors and examples of references related to evidence of their
association with peri-implantitis. The strength of risk (low, moderate, and high) and the strength of eviden-
ce is indicated for the various patient-, implant site-, and prosthesis-related factors.

Risk Supporting evidence

Factor/Indicator Low Moderate High Reference examples

Patient
Periodontitis Derks 2016, Kordbacheh Changi 2019,
No Yes Karoussis 2003, Ferreira 2006,
history
Roccuzzo 2010, Costa 2012
Kordbacheh Changi 2019,
Bone loss/Age < 0.5 > 0.5 - 1.0 > 1.0
Roos-Jansaker 2006

Periodontitis Stage 1 Stage 2 Stage 3 Cho-Yo Lee 2012, Derks 2016

susceptibility Grade A/B Grade A/B Grade A/C Kordbacheh Changi 2019

Roos-Jansåker 2006, Luterbacher 2000,

BOP% < 10% 10%-25% > 25%
Costa 2012, Vignoletti 2019

Pjetursson 2012, Cho-Yan Lee 2012,

N PD>5 mm ≤2 3-6 >6
Ferreira 2006, Koldsland 2011, Costa 2012
Costa 2012, Roccuzzo 2010, 2012,
Supportive care Compliant ≤ 6 months Casual/No Monje 2017, Ferreira 2006,
SPT Aguirre-Zorzano 2015

Medical status Healthy Compromised Ferreira 2006, Renvert 2014

Roos-Jansåker 2006, Rinke 2011,

Tobacco smoking 0 1-19 ≥ 20 cig
Schwarz 2017

Prosthesis
Kordbacheh Changi 2019, Serino & Ström 2009,
Cleanability Good Poor fit but No access
Heitz-Mayfield 2012, Katafuchi 2018
supramucosal
restorative
Fit/Design Well-fitting margin Ill-fitting Kordbacheh Changi 2019

Submucosal Kordbacheh Changi 2019, Linkevicius 2013,

Screw-retained Cement residue
excess cement Wilson 2009, Korsch 2015

Prosthetic margin 1.5 mm < 1.5 mm

Soft-tissue level Derks 2016
to bone crest mm

Site

Keratinised Adequate Minimal Absence Souza 2016, Ladwein 2015, Roccuzzo 2016
mucosa (≥ 2 mm) (< 2 mm)

This Checklist is taken from: L.J.A. Heitz-Mayfield. Risks for Peri-Implant Diseases.
ITI Treatment Guide, Vol. 13: Chapter 6; Pg 36. Quintessence Publishing: Berlin; 2022.
Aesthetic Risk
Assessment Table
This checklist is used to evaluate preoperative risk assessment for optimal esthetic outcomes during
implant therapy in the esthetic zone.

For further information on how to use this table, please refer to ITI Treatment Guide Vol.10*

Level of risk
Esthetic risk factor
Low Medium High

Health, Compromised healing

Medical Status
uneventful healing
Light smoker Heavy smoker
Smoking habit Non-smoker
(≤10 cigs/day) (> 10 cigs/day)
Gingival display
Low Medium High
at full smile
Width of 1 tooth (≥ 7 mm)1 1 tooth (< 7 mm)1
2 teeth or more
edentulous span 1 tooth (≥ 6 mm)2 1 tooth (< 6 mm)2

Shape of tooth crowns Rectangular Triangular

Restorative status
Virgin Restored
of neighboring teeth
Low-scalloped, Medium-scalloped, High-scalloped,
Gingival phenotype
thick medium-thick thin

Infection at implant site None Chronic Acute

Soft-tissue anatomy Soft-tissue intact Soft-tissue defects

Bone level ≤ 5 mm 5.5 to 6.5 mm ≥ 7 mm

at adjacent teeth to contact point to contact point to contact point
Facial bone-wall Thick-wall phenotype Thick-wall phenotype
phenotype* ≥ 1 mm thickness < 1 mm thickness
Bone anatomy Horizontal Vertical
No bone deficiency
of alveolar crest bone deficiency bone deficiency
Patientʼs esthetic
Realistic expectations Unrealistic expectations
expectations

* If three-dimentional imaging is available with tooth in place

1 Standard-diameter implant, regular connection
2 Narrow-diameter implat, narrow connection

* This Checklist is taken from: W. Martin, V. Chappuis, D. Morton, D. Buser. Preoperative

risk assessment and treatment planning for optimal esthetic outcomes. ITI Treatment
Guide, Vol. 10: Chapter 3; Pg. 30. Quintessence Publishing: Berlin; 2017
Surgical Techniques and
Grafting Protocol for Sinus Floor Elevation
This Decision Tree assists in providing clinical decision guidelines for choosing the surgical techniques
and grafting protocol for sinus floor elevation procedures

Antrophic posterior maxilla

Favorable interarch relationship
Insufficient bone height for standard implant placement

Vertical bone height: ≤ 6 mm or oblique sinus floor Vertical bone height: > 6 mm and horizontal sinus floor

SFE using Transcrestal SFE

the lateral window with simultaneous
technique implant placent

Primary implant stability achievable Primary implant stability not achievable

Grafting with
Simultaneous praticulated Grafting with
autogenous bone bone substitute Prosthetic loading
implant placement after 3 months
(alone or combined material alone
with a bone substitute
material)

Prosthetic loading
Implant placement Implant placement
after 3 to
after 4 to 8 months after 9 to 12 months
6 months

Prosthetic loading Prosthetic loading

after 3 months after 3 months

This Decision Tree is taken from: S. S. Jensen. Guidelines for choosing the surgical
technique and grafting protocol for sinus floor elevation. ITI Treatment Guide, Vol. 5,
Chapter 5: Pg 62. Quintessence Publishing: Berlin; 2011
Treating Peri-Implant Mucositis
and Peri-Implantitis
This flow chart assists decision when treating peri-implant mucositis and peri-implantitis.

EXAMINATION
Assess periodontical status. Assess potential risk factors e. g. smoking habits, diabetes.
Assess patient expectations
Modify potential risk factors as required.

Peri-implant probing
Radiograph Assess prosthesis — Assess patientʼs ability for
Obtain previous records if avaliable access for cleanability self-performed plague control

Peri-implant mucositis DIAGNOSIS Peri-implantitis

Explanation of disease and treatment
Discuss costs and possible adverse effects of treatment e. g. soft tissue recession

Rational to keep Irrational to keep

NON-SURGICAL TREATMENT

Modification of implant-supported Mechanical debridement — Individualized oral

prosthesis contours if required calculus, biofilm removal hygiene instructions

± Adjunctive measures e. g. air-polishing, probiotics, aPDT, local antimicrobials

Peri-implant health Re-assessment Persistent peri-implantitis

Resolution of inflammation Peri-implant probing Suppuration and/or BoP
Absence of BoP/suppuration Approx. 1 month PD ≥ 6 mm

Futher Peri-implant mucositis Peri-implantitis

non-surgical Persistent BoP BoP PD ≤ 5 mm
therapy

SURGICAL TREATMENT

Mucoperiosteal flap. Removal of inflamed granulation tissue. Decontamination of implant surface, e. g. chemical —
hydrogen peroxide, chlorhex idine; mechanical — ultrasonic, titanium brush; laser irradiation — ErYA G.
Adequate flap adaptation. Adequate postoperative care — antiseptics, ± periopenrative systemic antimicrobials.

Open-flap debridement Reconstructive therapy Resective therapy Implant removal

Type 1: CID Defects with an intrabony component:

Type 2: DD Type 1: CID Non-esthetic area: Due to extent of the defect
Type 3: CD Type 3: CD Type 4: CSD or if esthetic outcome will
Type 4: CSD Type 5: ID Type 5: ID be severely compromised
Type 5: ID

Bone graft/substitute ± membrane Spontaneous healing

Bone removal ± implantoplanty
± soft -tissue graft OR
Apically positioned flap
Hard and/or soft-tissue graft

SUPPORTIVE THERAPY

Regular monitoring (3- 5- monthly): professional biofilm removal; oral-hygiene reinforcement

This Decision Tree is taken from: L. J. A. Heitz-Mayfield, G. E. Salvi. Treatment

of Peri-Implantitis. ITI Treatment Guide, Vol. 13: Chapter 8, Pg.59. Quintessence
Publishing: Berlin; 2022.
 DECISION TREE: IMMEDIATE PL ACEMENT AND LOADING IN PARTIALLY EDENTULOUS PATIENTS–SINGLE ANTERIOR TEETH
Creation of decision tree: German Gallucci, Adam Hamilton, Will Martin, Stephen Chen, Daniel Wismeijer, Kati Benthaus, Charlotte Stilwell.

Tooth PRE-OPERATIVE ASSESSMENT1 INTRA-OPERATIVE ASSESSMENT PLACEMENT PROTOCOL LOADING PROTOCOL

requires
extraction For Type A loading protocol,
Thick soft tissue phenotype, the following criteria must be present:
absence of recession 1. insertion torque > 35 Ncm or ISQ > 70
Implant and low esthetic risk 2. no direct occlusal contacts
option 3. no parafunction
confirmed
Loading Protocol 3
Immediate Early Conventional
Pre-op CBCT assessment of site confirms: Intra-op assessment of site confirms: restoration/ loading
loading

x
1. socket intact and facial socket wall thickness 1. socket wall intact loading (Type A) (Type B) (Type C)
of at least 1 mm 2. primary stability achievable TYPE I2 Implant placement protocol
2. enough bone available apical and palatal to 3. ideal implant position achievable (Immediate) Immediate Type 1A CD Type 1B CD Type 1C SCV
the socket to provide sufficient primary stability placement
(Type 1)
EVIDENCE BASED DENTISTRY 3. socket position within alveolar bone envelope
(EBD) 4. horizontal defect of at least 2 mm CD (yellow): clinically documented; CID (red): clinically
(at implant shoulder) insufficiently documented (includes loading protocols that are
Patient not documented); CWD (green): clinically well documented;
5. no infection at the site SCV (green): scientifically and clinically validated.

EBD
Loading Protocol 3
Clinician Evidence 1. socket not intact and facial socket wall 1. facial bone wall compromised by
Immediate Early Conventional
thicknes of < 1 mm dehiscence or fenestration restoration/ loading
loading
2. inadequate bone available apical and palatal 2. damage to surrounding soft tissue TYPE II–III2 loading (Type A) (Type B) (Type C)
to the socket to provide sufficient primary 3. primary stability not achievable (4–16 weeks) Implant placement protocol
stability 4. ideal implant position compromised Early Type 2–3A CID Type 2–3B CID Type 2–3C SCV
SAC CLASSIFICATION 3. socket and facial bone wall protruding out 5. infection debrided placement
(Type 2–3)
According to the ITI’s SAC of the bone envelope
Classification immediate 4. infection at the site CD (yellow): clinically documented; CID (red): clinically
placement and loading pro- insufficiently documented (includes loading protocols that are
not documented); CWD (green): clinically well documented;
tocols represent advanced SCV (green): scientifically and clinically validated.
to complex procedures that
may be associated with
Loading Protocol 3
advanced to high overall
Immediate Early Conventional
treatment risk. restoration/ loading
loading
RIDGE PRESERVATION TYPE IV 2
loading (Type A) (Type B) (Type C)
Surgial classification 1. clinical situation incompatible with Type I–III OR (4–6 months*) Implant placement protocol
implant placement FORMAL GRAFT Late Type 4A CD Type 4B SCV Type 4C SCV
S A C *(depending on bone grafting) placement
(Type 4)
Prosthodontic classification
CD (yellow): clinically documented; CID (red): clinically
S A C insufficiently documented (includes loading protocols that are
not documented); CWD (green): clinically well documented;
SCV (green): scientifically and clinically validated.

1
Chen ST, Buser D. Clinical and esthetic outcomes of implants 2
Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommen- 3
Gallucci GO, Hamilton A, Zhou W, Buser D, Chen S. Check out the learning pathway
placed in postextraction sites. Int J Oral Maxillofac Implants. ded clinical procedures regarding the placement of implants in extraction Clin Oral Implants Res. 2018 Oct:29 Suppl 16: 106–134 on immediate implant placement on
2009; 24 Suppl: 186–217. PMID: 19885446. sockets. Int J Oral Maxillofac Implants. 2004;19 Suppl:26-8. PMID: 15635943 the ITI Academy: visit us at WWW.ITI.ORG

LEGEND YES NO