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20 GENERAL DENTISTRY Dental Tribune Middle East & Africa Edition | 3/2017 Surgical management of peri-implantitis Specialist Periodontist, Dr Jeremy Vo, explains how he has embraced AIR-FLOW® technology in the management of Peri-Implantitis By Dr Jeremy Vo Surgical intervention is often re- quired in the treatment of advanced peri-implantitis lesions. Peri-implan- titis is defi ned as an infl ammatory process around an implant, with soft tissue infl ammation and loss of sup- porting marginal bone.1 The aim of surgical therapy is to al- low access for the decontamination of implant surfaces which have been exposed to oral biofi lms. Several ap- proaches for implant decontamina- tion have been described and can be broadly categorised to include me- chanical, chemical and laser instru- ments.2 Mechanical removal of hard and soft deposits can be achieved with rubber cups, curettes, and/or ultrasonic de- vices.2 Curettes of different materials have been manufactured, specifi - cally for the debridement of implant surfaces. These materials include steel, titanium, carbon-fi ber, Tefl on and plastic. Ultrasonic devices with polyetheretherketone (PEEK)-coated tips are also specifi c for implant sur- faces. A more aggressive approach has been proposed which involves intentional removal of the implant threads. This is known as ‘implanto- plasty’ and the aim is to produce a polished, smooth collar which bet- ter supports oral hygiene compared with the original rough surface of the implant. Chemical decontamination is aimed at disinfecting the implant surface by direct application during sur- gery.3 Following elevation of the soft tissues, the implant surface can be rinsed with several different sub- stances including chlorhexidine, so- dium chloride, hydrogen peroxide and citric acid. Unfortunately, no chemical agent has shown superior results when compared with others.4 Figure 1. Radiographic assessment at baseline. Laser decontamination - includ- Figure 2a-c. Pre-operative clinical photographs. ing the use of Er:YaG and CO2 la- sers - have also been utilised during surgery in an attempt to improve clinical outcomes. The evidence is, however, weak and has not shown signifi cant improvement when compared with conventional me- chanical therapy.5 There are 3 main approaches for sur- gical intervention including:3 Access surgery The primary aim of access surgery is to decontaminate the implant surface.3 Commonly, intrasulcular incisions will allow the conservation of the soft tissues around the im- plant once the mucoperiosteal fl aps are elevated. Infl amed peri-implant tissues are degranulated and the implant surface is decontaminated. A clinical study with 5 years follow up reported complete resolution of advanced peri-implantitis lesions in 42% of implants and 63% survival of implants.6 Resective surgery This surgical technique allows im- plant decontamination to take place; but rather than conserving soft tis- sues, a reverse beveled incision com- bined with osteoplasty reduces the pocket depths around the implant.3 As a result, the neck of the implant is usually left exposed to the oral cav- ity and therefore, this technique is only suggested for implant defects in non-aesthetic areas. The 2-year out- come of resective peri-implantitis surgery found complete resolution of clinical signs of disease in almost 60% of implants.7 Regenerative surgery Regenerative surgery is aimed at improving hard tissue integration around the implant (re-osseointegra- tion) as well as minimising recession of the peri-implant mucosa.3 Follow- ing mucoperiosteal fl ap elevation, the implant surface is decontami- nated and the intrabony defect is degranulated. Various approaches to bone grafting have been described. Bone substitute materials such as Bio-Oss® (Geistlich Biomaterials) can be used to fi ll the intrabony defect which is then covered with a resorb- able or nonresorbable membrane. A 4-year clinical study found signifi - cant reductions in probing pocket depth and radiographic defect fi ll with a regenerative technique in- volving Bio-Oss® and Bio-Gide®.8 The clinical approach The development of biofi lm on the implant surface plays a signifi cant role in the initiation and progres- sion of peri-implant diseases. The bacterial microfl ora is composed predominantly of Gram-negative anaerobes and is similar to micro- fl ora found around teeth with severe periodontitis.9 Unfortunately, in the management of peri-implantitis, no defi nitive gold standard has been identifi ed for implant decontamina- tion. Implant surface roughness and irregularities can enhance bacterial attachment and prevent adequate instrumentation. The tips of the cu- rettes are often too large to reach the deeper parts of the thread. Recently, a powered air-abrasive system utilising Erythritol (a sugar substitute) has been proposed as an effective method of biofi lm removal from the implant surface that is safe on hard and soft tissues (EMS AIR- FLOW® EL-308/A; Electro Medical Systems (EMS)).10 The abrasiveness of Erythritol is low and it does not cause extensive damage to the surface to- pography of the implant compared with the use of conventional steel curettes or ultrasonics. Furthermore, in vitro data suggests that it has an antimicrobial effect.11 Once the implant surface has been decontaminated, the morphology of the bony defect may help determine the most suitable surgical approach. Generally, if the defect is circumfer- ential with intact bony walls, or has an intrabony component, the use of a regenerative approach will provide improved clinical outcomes. On the other hand, if the defect is supra- bony or the implant presents with some degree of buccal dehiscence, an apically repositioned fl ap would be indicated in these non-aesthetic areas. ÿPage 21