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ePaper created 2016-09-14, 10:51:37 | version 1.38.0
The prevalence of peri-implant complications is significantly rising clinically as implant treatment in- creases in the US. Peri-implantitis is a frequent enough occurrence in the dental practice that treatment needs to be accomplished to pre- vent loss of the implant. As with periodontitis associated with natu- ral teeth, periodontal disease can affect implants. This can range from gingival inflammation in the absence of bone loss to significant bone loss when the disease process is not identified early in the process or a wait and see attitude is taken that leads to significant bone loss and then mobility of the fixture. Treatment has traditionally involved elevating a flap at the site and mechanical debridement with surgical hand instruments to remove any granulation tissue present on the implant threads. Owing to the limitations of the surgical tools, this might require removal of additional bone to at- tempt to reach areas not visible. Success depends on debriding and sterilising all exposed threads, with success diminishing as more surface area is left untreated. Owing to the small diameter of their flexible glass fibres, diode lasers offer several benefits for peri-implantitis treatment. This includes easier access to areas with limited access without the need to remove as much bone as may be required when only surgi- cal instruments are utilised. Fur- thermore, the diode laser has the ability to sterilise the implant’s contaminated surface, eliminat- ing any bacteria that caused the disease to prevent their hamper- ing healing after treatment. An added benefit is biostimulation of the mesenchymal stem cells in the surrounding bone and soft tis- sue. This is important for regener- ative therapy and tissue engineer- ing to provide better healing.1 Thus, the diode laser is a good adjunct in the treatment of peri-implantitis, improving the clinical results observed with con- ventional methods.2 Case presentation A 64-year-old male patient presented in June 2010 with a fis- tula draining on the buccal aspect of the maxillary right canine. The fistula was located distal to the ca- nine midline in close proximity to the gingival margin (Fig. 1). A gut- ta-percha cone was inserted into the fistula to trace the origination point of the draining infection and a radiograph was taken. Radi- ographically, it was determined that the fistula could be traced to the apex of the implant situated at site #13 (maxillary right canine). Implants replacing teeth #12–16 had been placed and restored sev- eral years before. The implants at sites #13, 14 and 15 were identified as Brånemark System Mk III RP and the implant at site #12 as NobelReplace (both Nobel Biocare). Another image was taken to evaluate the underlying osseous structure around the implant, and it demonstrated a radiolucency around the apex of implant #13 (Fig. 2) and crestal bone loss with thread exposure under the soft tissue at implant #12. Clinically, no recession was noted and no implant mobility detected. The patient was informed of the clinical issue identified and the options available, which in- cluded removal of the ailing im- plant and grafting the site. After the integration of the graft, a new implant could be placed and then restored after an appropriate healing period. The other option would be elevating a flap in the area, cleaning out any granula- tion tissue and treating the site with a diode laser and graft to re- place any lost bone. The patient was also informed that, should the latter option be selected, the site would need to be evaluated once entered and there was the possibilitythattheimplantwould need to be explanted should it be found to demonstrate mobility after the area had been debrided. The patient chose to attempt peri-implantitis repair and the necessary consent forms were signed. An antibiotic (2 g amoxicillin) was administered orally 1 hour prior to the initiation of treat- ment. A local anaesthetic (Septo- cainewithepinephrine1:100,000; Septodont) was administered for local infiltration at the buccal and palatal aspects of the treatment area. A horizontal incision was made from the distal aspect of the first premolar to the mesial aspect of the lateral incisor several mil- limetres apical to the gingival margin in order to limit poten- tial postoperative recession. A vertical releasing incision was made at the mesial and distal extents of the horizontal incision and a full-thickness flap was elevated. Upon flap reflection, it was observed that a large de- hiscence was present on implant #13, from the crest to several mil- limetres past the apex of the implant. Additionally, some de- hiscence was noted on the buccal aspect of implant #14, with threads minimally covered with bone over the apical half of the implant. Implant #12 presented with 30 to 50 per cent of the threads circumferentially of the implant denuded of bone with complete soft-tissue coverage. A hand instrument was used to remove any gross granulation tissue adherent to the bone and exposed implant threads (Fig. 3). An activated 300 µm diode tip on the Picasso laser (AMD LASERS), set at 1.5 W in continuous mode, was used to remove any residual granulation tissue on the exposed threads at the defect and sterilise the defect area.3, 4 The diode’s fibre tip was placed into physical con- tact with the implant surface to remove any residual granulation tissue and sterilise the area of any bacteria that had contributed to the peri-implantitis, leaving clean threads. After debridement and sterili- sation, bleeding points in the os- seous walls were created. Geistlich Bio-Oss (Geistlich Pharma North America), a biocompatible porous bovine bone mineral substitute, was packed into the defect around the implant and allowed to absorb blood from the surrounding tis- sue to form a coagulated mass. The osseous graft was built out buccally to create a new buccal plate covering the entire implant below the crestal level (Fig. 4). A piece of OSSIX PLUS (OraPharma), a resorbable membrane, was trimmed to overlay the osseous graft and end on native bone and was placed over the graft under the flap. The flap was repositioned andsecuredwithnineinterrupted sutures using 5-0 silk to achieve primary closure. A radiograph was taken to doc- ument the bone fill of the osseous graft (Fig. 5). Haemostasis was con- firmed and the patient dismissed. A prescription was given for a Z-Pak (ZITHROMAX, Pfizer) with the instructions to use as directed until finished, as well as for Dolo- bid 500 mg (Merck) to be taken b.i.d. for pain for the initial three days postoperatively. The patient returned after one week for suture removal and indicated that no sig- nificant postoperative discomfort had been felt. The site appeared to be healing normally and he was scheduled for a follow-up to check healing. At the next postoperative visit, the site appeared healed with a lack of inflammation and the patient was placed on periodontal recall, alternating with visits to his general dentist. At a five-year postoperative visit, a CBCT scan was taken to evaluate the long-term status of the repaired area. The cross-sec- tional slice at the right maxillary 18 Dental Tribune Asia Pacific Edition | 9/2016 TRENDS & APPLICATIONS Peri-implantitis treatment with the Picasso diode laser A five-year case follow-up Drs Gregori M. Kurtzman, Markus Weitz, Ron Kaminer and Daniel D. Gober, US “...the diode laser is a good adjunct in the treatment of peri-implantitis, improving the clinical results observed with conventional methods.” Fig. 1: Fistula present distal of the maxillary right canine in close proximity to the gingival margin.—Fig. 2: Initial radiographic presentation demonstrating a large radiolucency around the apical half of the implant at site #13.—Fig. 3: After elevation of a full-thickness flap and removal of the granulation tissue with the Picasso diode laser, a lack of buccal bone was observed down the entire length to the apex.— Fig. 4: Osseous graft material was placed into the defect that had been cleaned with the Picasso diode laser and built out to the proper contour for the buccal plate. 1 2 3 4 1234