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Dental Tribune Middle East & Africa Edition No.2, 2016

Figure1.Fistulapresent at thedistalof themaxil- laryright canineincloseproximity to thegingival margin. Figure 5: Periapical radiograph taken post-surgically demonstrating defect filledwith theosseousgraft material. Figure 8: Periapical radiograph at 5-year follow-up. Figure 6 & 7: CBCT of a cross section (6.) and coronal slice (7.) of site No. 6 taken 5 years after peri-implantitis treatment demonstrating maintenance of the buccal plate and no return of the initial periodon- talproblem. Figure 2: Initial radiographic presentation demonstrating a large radiolucency around the apical half of the implant at site No. 6. Figure 3: Following a full-thickness flap and removal of the granulation tissue with the Picasso diode laser, a lack of buccal bone is noteddown theentirelength to theapical.Figure4:Osseousgraft materialwasplacedinto thedefect that hadbeencleanedwith thePicassodiodelaserandbuilt out to thepropercontourfor thebuccalplate Treatment of Peri-Implantitis with the Picasso Diode Laser A long-term follow-up after debridement and grafting By Gregori M. Kurtzman, DDS, MAGD, Markus Weitz, DDS, Ron Kaminer,DDS,DanielD.Gober,DDS The prevalence of peri-implant complications is rising significantly as implant treatment increases. Periodontal disease associated with implants can range from gingival inflammationintheabsenceofbone loss to significant bone loss and mo- bility of the fixture. The latter can occur when the disease process is not identified early in the process or a“watchandwait”attitudeistaken. Treatment has traditionally in- volved flap elevation and mechani- cal debridement with surgical hand instruments to remove any granu- lation tissue present on the implant threads. As a result of the limitations of surgical tools, removal of addi- tional bone might be required to reachareasthatarenotvisible. Success diminishes as more sur- faceareaisleftuntreated. Diode lasers have several ben- efits related to peri-implantitis treat- ment. The small diameter of the flexible glass fiber allows easier and more complete access without the need to remove as much bone as when only surgical instruments are utilized. Additionally, the diode has the ability to sterilize the implant’s contaminated surface, eliminating any existing bacteria and keeping them from preventing healing after treatment.1 The added benefit of us- ing a diode in these procedures is biostimulation of the mesenchymal stem cells in the surrounding bone and soft tissue, an important tool for regenerative therapy and tissue engineering to provide better heal- ing.2,3 Thus, the diode laser is a good adjunct in the treatment of peri-im- plantitis, improving the clinical re- sults observed with more traditional methods.4 CasePresentation A 64-year-old male patient pre- sented in June 2010 with a fistula draining on the buccal of the upper right canine. The fistula was located distal to the canine midline in close proximity to the gingival margin (Figure 1). A guttapercha cone was inserted into the fistula totrace the origination point of the draining in- fection and a radiograph was taken. It was determined that the fistula traced to the apical of the implant situated at site No. 6. Implants had been placed and restored for teeth Nos. 3 through 7 several years previ- ously. The implant was identified as a Brånemark Mark III RP (Nobel Bio- care, at site Nos.4through6,andaNobelReplace (Nobel Biocare) at site No. 7. A radio- graph was taken to evaluate the un- derlying osseous structure around theimplant,whichdemonstratedra- diolucencyassociatedwiththeapical ofimplantNo.6andcrestalboneloss with thread exposure under the soft tissue on implant No. 7. Clinically, no recession was noted and no implant mobilitywasdetected. The patient was informed of the clinical issues and the available options, including removal of the ailing implant, grafting the site, and placing and restoring a new implant after an appropriate healing period. The other option would be elevating a flap, cleaning out any granulation tissue, and treating the site with a diode laser and graft to replace any lostbone. He was also informed that the latter option meant that the site would need to be evaluated once entered and there was a possibility that the implant would need to be explanted should it exhibit mobility following debridement. The patient choseperi-implantitisrepair. Preoperative antibiotics (2.0 g amoxicillin) were given orally 1 hour prior to the initiation of treat- ment. A local anesthetic (Septo- caine® 1:100,000 with epinephrine, Septodont, www. was administered for local infiltra- tion on the buccal and palatal of the treatment area. A horizontal incision was made from the distal of the first premolar to the mesial of the lateral incisor several millimeters apical to the gingival margin to limit post- treatment recession potential. A vertical releasing incision was made at the mesial and distal extent of the horizontal incision and a full-thick- nessflapwaselevated. Upon flap reflection, it was not- ed that a large dehiscence was pre- sent on tooth No. 6 from the crest to several millimeters beyond the apical of this implant. Additionally, some dehiscence was noted on the buccal of implant No. 5 with threads minimally covered with bone over theapicalhalfoftheimplant. Site No. 7 presented with 30% to 50%ofthe threads circumferentially denuded of bone with complete soft tissuecoverage. A hand instrument was utilized to remove any gross granulation tissue adherent to the bone and ex- posedimplantthreads(Figure3). An activated 300-μm diode tip on the Picasso laser (AMD Lasers, set at 1.5 W in continuous mode was used to re- move any residual granulation tis- sue on the exposed threads at the defect and sterilize the defect area.5,6 The diode’s fiber tip was placed into physical contact with the implant surface to remove any residual granulation tissue and sterilize the area of any bacteria that contributed to the peri-implantitis, leaving clean threads. Followingdebridementandster- ilization, bleeding points in the osse- ouswallswerecreated. Geistlich Bio-Oss® (Geistlich Pharma North America Inc., www., a bovine biocom- patible porous bone mineral sub- stitute, was packed into the defect around the implant and allowed to absorb blood from the surrounding tissue to form a coagulated mass. The bone graft was built out buc- cally to create a new buccal plate covering the entire implant below the crestal level (Figure 4). A piece of resorbable membrane (Ossix® Plus, OraPharma, Inc, www.orapharma. com) was trimmed to overlay the os- seous graft and end on native bone and was placed over the graft under the flap. The flap was repositioned and secured with nine interrupted sutures using 5-0 silk to achieve primary closure. A radiograph was taken to document the bone fill of the osseous graft (Figure 5). Hemo- stasis was confirmed and the patient dismissed. A prescription for a Z-Pak (Zithromax®, Pfizer, com)wasgivenwiththeinstructions to use as directed until finished. Ad- ditionally, a prescription was given forDolobid®(Merck&Co.,Inc.,www. 500 mg for pain to be takentwicedailyfortheinitial3days post-surgically. The patient returned after 1 week for suture removal and indicated no significant postopera- tive discomfort. The site appeared to be healing normally and he was ap- pointedforafollow-uptocheckheal- ing. At the next postoperative visit, the site appeared healed with a lack ofinflammationandthepatientwas placed on periodontal recall alterna- tivewithhisgeneraldentistoffice. At 5 years post peri-implantitis treatment, cone-beam computed tomography (CBCT) was used to evaluate the long-term status of the repaired area. The cross section slice attherightmaxillarycaninedemon- strated that the grafted buccal plate remained at the position completely covering the implant with no sign of further infection noted (Figures 6 and 7). A periapical radiograph con- firmedosseointegration(Figure8). Discussion Managing peri-implantitis can beachallenge.Asthiscaseillustrates, bone loss may be progressing for an extended period of time before the clinician becomes aware of it. Treat- mentrequires asurgicalapproachto remove any granulation tissue that hasreplacedboneoverlayingtheim- planttoachieveanysuccess. The benefit of the Picasso diode laseristhefibercanbeextendedinto hard-to-reach areas around the im- plant to achieve better sterilization and debridement without the need toremoveadditionalboneforaccess, which would be necessary if only de- bridementwithsurgicalhandinstru- mentswasutilized. Traditional methods have re- ported mixed results in removing all of the granulation tissue from the exposed implant threads without altering or gouging the implant’s surface or coating. A pulsed Er:YAG laser has also been reported to cause implantsurfacealterations.7,8 Scanning electron microscope analysis has demonstrated no dam- ÿPage3 Dental Tribune Middle East & Africa Edition | 2/2016 implant tribune 2

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