implants - the journal of oral implantology UK Edition

I 13 case report_ Er YAG lasers I implants1_2012 been placed four years earlier and that looseness of the crown had occurred on two occasions during this period.Onbothoccasions, the screw hadbeenretight- ened with no further investigation. Clinical examination of the patient revealed a miss- ing tooth at the location of #9 with no sign of an im- plant (Fig 1). The patient brought the abutment, crown andbrokenscrewwithhim(Fig3).Radiographicexami- nationoftheareashowedthepresenceofaroot-form cylindrical implant, consistent in appearance with a 13mm long, 3.75mm diameter abutment with an internal hex. The apical part of the screw remained threadedintotheimplant,buthadfracturedatthelevel of the hexagonal lock. Although the implant was os- seointegrated, there were radiographic signs of peri- implantitis with some crestal bone loss having oc- curred (Fig 2). _Treatment options The treatment options available were: 1) retrieve the fractured screw, or 2) remove the old implant and insert a new implant in one sitting. Following discus- sion with the patient and evaluation of the possibili- ties for success, it was decided to try and retrieve the fractured screw. Treatment would involve the use of the Er:YAG laser to perform the following, based upon accepted research: • The flap incision31,32,33 • Ablation of granulation tissue around the implant 34,35,36 •Remodelling,shapingandablatingofthebone32,34,37,38 • Detoxification of the infected surfaces of the im- plant36,39,40,41,42 • An associated osteogenic (GBR) procedure to pre- vent soft tissue in-growth and maintain the form of the alveolus treatment alternatives, using a more conventional approach, would include the use of tra- ditional scalpel, curettage, and rotary instruments _Treatment A dual-wave laser system with operating wave- lengthsof2,940nmand10,600nm(OpusDuo™AquaL- ite™, Lumenis, Ltd. Yokneam, Israel) was employed for this procedure. The laser operating parameters em- ployed for the various surgical stages were as follows: • Flap Access: Wavelength: 2,940nm (Er:YAG), 200- micron sapphire tip, in contact mode; 450 mJ per pulse at 20 Hz. Total power: nine Watts • Granulation Tissue Removal: Wavelength: 2,940nm (Er:YAG), 1,300-micron sapphire tip, in non-contact mode;700mJperpulseat12Hz.Totalpower:8.4Watts • Bone Surgery: Wavelength: 2,940nm (Er:YAG), 1,300-micron sapphire tip, in non-contact mode; 450mJ per pulse at 20Hz. Total power: nine Watts • Detoxification of the implant: Wavelength: 2,940nm (Er:YAG), 1,300-micron sapphire tip, in non-contact mode; 150mJ per pulse at 20Hz. Total power: three Watts • Decortication for GBR technique: Wavelength: 2,940nm (Er:YAG), 1,300-micron sapphire tip, in non- contact mode; 500mJ per pulse at 17Hz. Total power: 8.5Watts A “V” shape incision was made with the Er:YAG laser. An intrasulcular incision was made (after anaes- thesia) at the buccal and palatal side of the implant, together with two vertical relieving incisions: one at the mesial side of tooth #8 and the second at the me- sial side of tooth #11 (Figs 4 and 5). The buccal and palatal flaps were lifted and the area explored (Fig 6); there was granulation tissue around the neck of the implant. The granulation tis- sue was ablated using the laser (Fig 9). Vaporisation of granulation tissue (if any exists) after raising a flap is efficient with the Er:YAG laser, offering a lower risk of overheating the bone than that posed by the cur- rent diode or CO2 lasers.43 And often obviates the need for hand instruments. Results from both controlled clinical and basic studies have pointed to the high po- tential of the Er:YAG laser and its excellent ability to effectively ablate soft tissue without producing major thermal sideeffects to adjacent tissue has been dem- onstrated in numerous studies.35,36,37 Fig. 17 Fig. 18 Fig. 19 Fig. 20