Dental Tribune Asia Pacific No. 9, 2016

19Dental Tribune Asia Paciﬁc Edition | 9/2016 TRENDS & APPLICATIONS Europe Clinical MastersTM Program in Esthetic and Restorative Dentistry Three sessions with live patient treatment, hands-on practice, plus online training under the Masters’ supervision. Learn from the Masters of Esthetic and Restorative Dentistry: 12 days of intensive live training with the Masters in Geneva (CH), Athens (GR), Milan (IT) 12 days of live training with the Masters in Geneva (CH) , Athens (GR), Milan (IT) + self study Curriculum fee: €9,900 (Based on your schedule, you can register for this program one session at a time.) Registration information: contact us at tel.: +49-341-484-74134 email: request@tribunecme.com Details on www.TribuneCME.com Online access to our library of Lectures & Clinical Videos Tribune Group GmbH is an ADA CERP provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. 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CREDITS Certificates will be awarded upon completion AD 5 6a 6b Fig. 5: Periapical radiograph taken post-op demonstrating the defect ﬁlled with the osseous graft material.—Figs. 6a & b: CBCT scan of a cross-section (a) and coronal slice (b) of site #13, demonstrating maintenance of the buccal plate ﬁve years after peri-implantitis treatment and no return of the initial periodontal problem. canine demonstrated that the graftedbuccalplatehadremained in position, completely covering the implant. No signs of fur- ther infection were visible (Figs. 6a & b). Discussion Peri-implantitis can be a chal- lenge to manage. As this case illus- trates, bone loss may have been progressing for an extended pe- riod before the clinician becomes aware of it. In order to achieve any success, treatment requires a surgical approach to remove any granulation tissue that has re- placed bone overlaying the im- plant. The beneﬁt of the Picasso diode laser is that the ﬁbre can be extended into areas around the implant that are difﬁcult to reach in order to achieve better sterilisa- tion and debridement without the need to remove additional bone for access, as would be necessary were only debridement with surgical hand instruments per- formed. The diode tip ensures better removal of the granulation tissue and site sterilisation to in- crease treatment success. Conventional methods have reported mixed results regarding the ability to remove all of the granulation tissue from the ex- posed implant threads without altering the implant surface. The diode laser has been reported not to cause any visible surface altera- tions of either polished or coated implant surfaces. In contrast, sur- face alterations have been re- ported when irradiated with the pulsed Er:YAG laser.5, 6 Scanning electron microscopy analysis has demonstrated no damage or alteration of titanium surfaces when in contact with a diode laser, regardless of the power setting. No visible differ- ence between lased and non-lased titanium surfaces after irradia- tion has been reported. The result yields the best surface for guided tissue regeneration compared with either mechanical debride- ment, which can alter the surface by gouging the titanium or coat- ing, or use of an Er:YAG laser. Success in peri-implantitis treatment is strongly linked to the ability to eliminate the bacteria in the site that could hamper regen- eration. This becomes more criti- cal with implants that have been surface treated during manu- facture to provide a better surface for integration. These manufac- turer-treated implant surfaces yield a micro-roughness that bone responds well to during the initial integration, but that will harbour bacteria when peri-implantitis has occurred. Their removal in these micro-irregularities is difﬁ- cult to achieve by mechanical means. The diode laser has the ability to decontaminate the ex- posed surface and threads with- out any negative effects.7 Once the site has been pre- pared, with the granulation tissue removed and all exposed surfaces decontaminated, osseous grafting is required to ensure the best heal- ing long term. Without placement of osseous graft material to ﬁll the osseous defects that resulted from the peri-implantitis, the site will most likely not achieve bone ﬁll via organisation of a host clot in the void. Membranes too are rec- ommended to allow the body to organise the osseous graft mate- rial before soft-tissue ingrowth can occur from the overlaying ﬂap, as soft tissue grows and heals at a much faster rate than hard tis- sue does. The membrane gives the hard tissue an advantage to over- come the soft tissue’s potential to invade the early osseous graft ma- terial. Placement of osseous graft material and barrier membranes has resulted in greater probing depth reduction and radiographic bone ﬁll when either material is not used.8 The authors recommend avoiding probing these sites during the healing phase and thereafter because of the arrange- ment of connective tissue ﬁbres found around implants. Implants, when viewed via a scanning elec- tronic microscope, have the ﬁbres in the gingival aspect where it connects with the implant sur- face running parallel to the long axis of the implant. This does not provide a physical barrier to the probe, allowing it to push bacteria deeper into the tissue, which may lead to inﬂammatory changes in the tissue. The ﬁbre orientation around natural teeth is perpen- dicular to the tooth’s long axis, providing a physical barrier to the probe. Conclusion The key to successful peri- implantitis treatment is early identiﬁcation to limit bone loss due to the inﬂammation and in- fection. The diode laser is a power- ful adjunct in treating peri- implantitis, allowing better access to eliminate more granulation tis- sue than when only mechanical means are employed. It also pro- vides the additional beneﬁts of sterilisation of the area and bi- ostimulation of the bone and soft tissue to improve tissue regener- ation. This case illustrated that the protocol presented can pro- vide long-term predictable re- sults, showing ﬁve-year mainte- nance of the grafted area and an absence of inﬂammation over that time. Acknowledgement The case was treated by Dr Markus Weitz. Editorial note: A list of references is available from the publisher. Dr Daniel D. Gober is main- taining a pri- vate practice in Cedarhurst, New York, in the US. DrRonKaminer is maintain- ing a private practice in Hewlett and O c e a nsi d e , New York, in the US. Dr Markus L. Weitz is main- taining a pri- vate practice in Cedarhurst, New York, in the US. Dr Gregori M. Kurtzman is maintaining a private prac- tice in Silver Spring, Mary- land, in the US. He can be contacted at drimplants@aol.com.

Dental Tribune Asia Pacific No. 9, 2016

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