C2 ◊Page C1 IMPLANT TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2019 plants, pterygoid implants and pala- tal implant mesh, with questionable results, but definitely decreasing the cleanability and maintainability of implants and prostheses. Dental hygienist skills and devices This professional figure plays a key role in disease prevention and oral health promotion.9 Dental hygien- ists should not limit their activities to being an oral cleaner, but act as the patient’s dental coach or person- al oral trainer, motivating patients not only in dental habits but also in lifestyle, for example regarding smoking cessation and diet. This is a friendly expert who strengthens patient fidelity to the dental office, even in fearful patients, and main- tains restorative work and rehabilita- tions undertaken by the dentist.10 To perform professional care in a minimally invasive way, wearing loupes and using plaque disclos- ing agents and appropriate devices are mandatory, especially if pros- thetic rehabilitation is difficult for the patient to maintain. Correct and periodic biofilm removal should be considered the standard of care for prevention and management of peri-implant disease.11 For this rea- son, patients should be motivated and instructed in daily implant maintenance, which should begin before implant placement and be continued after treatment within a regular, personalised recall regime (Figs. 4 & 5). Surgeon skills Nowadays, especially in Italy, a new professional figure has appeared: the implantologist, who is a gradu- ate dentist, generally a coworker, and goes to different dental offices or clinics and mainly places implants, often without sufficient expertise in periodontal and prosthetic fields. That means, in some cases, implant mispositioning, resulting in recon- structive and maintenance prob- lems. In order to avoid fabrication of specific prosthetic parts, unrestored implants and surgical interventions to remove or reposition them in fa- vourable prosthetic positions, this surgical intervention should only be performed by an elite clinician.7 This is an expert dentist with the necessary surgical skills to manage both soft and hard tissue (before and after implant placement) perfectly and with adequate expertise in the prosthetic field to allow a prothesis- guided implant surgery and, subse- quently, a functioning, not overload- ed, patient-tailored, cleanable and aesthetically pleasant rehabilitation. Prosthodontist skills Skilled clinicians know that there is no such thing as a gold standard prosthesis, but every patient needs a tailored rehabilitation, which takes into consideration his or her resourc- es and requirements and which has to be planned before surgical in- tervention. After data collection and decision planning regarding the numbers of implants requested, To- ronto versus overdenture, cemented versus screwed work, with a moti- vated and aware patient, the surgi- cal and prosthetic work with careful load management can start.12 Only careful and considerate planning can prevent poor outcomes (Fig. 6). Prosthesis fabrication and cementation Dental technicians should work in direct contact with prosthodontists in order to create aesthetically pleas- ant, patient-tailored and comfort- able cleaning spaces. After dental hygienist instruction and training, patients should be able to clean their prostheses daily with minimal ef- fort to maintain healthy mouths.13 Another important factor associated with clinical signs of peri-implant disease is excess cement.14–17 To avoid excess cement, restoration margins should be located at or above the peri-implant mucosal margin; oth- erwise, excess cement must to be removed.18 Despite world literature demonstrat- ing an increased interest in excess cement as one of the key factors in aetio-pathogenesis of peri-implant disease, a standard protocol guiding clinicians in this delicate removal procedure is still needed. From the authors’ point of view, the cementa- tion procedure requires time, atten- tion, loupes and meticulousness. For these reasons, an accurate protocol, dependent on cement composition, should be published (Figs. 7 & 8). Conclusion Implant rehabilitation provides a therapeutic alternative that is more similar to natural teeth than other alternatives. Nevertheless, while an implant-supported prosthesis can be a permanent successful solution, it lasts only if carefully planned with the patient, properly surgically per- formed, correctly loaded, and con- stantly maintained by the patient and the dental professionals. Suc- cessful results can be achieved only by an expert, patient-centred dental team. For more information contact: Prof. Magda Mensi, DDS Department of Medical and Surgical Specialties, Radiological Science and Public Health University of Brescia Brescia, Italy E-mail: magdamensi@gmail.com Peri-implantitis therapy Using resorbable bone replacement material By Dr Fernando Duarte, Portugal & Dr Gregor Thomas, Germany field thus needs to be conducted (Es- posito et al.). Peri-implantitis is one of the medi- cal challenges of the 21st century. Implantologists and periodontists around the world are consistently searching for reliable and imple- mentable therapy solutions. The au- thors presented their preferred pro- tocol of peri-implantitis treatment in this clinical case using a biomimetic bone replacement material and a re- sorbable collagen membrane. Peri-implantitis is defined as a lo- cal lesion which is associated with bone loss around an osseointegrated implant, whereas peri-implant mu- cositis is a reversible inflammatory change in the mucosa surrounding the implant. Peri-implant mucositis is diagnosed by probing, that is followed by bleed- ing. The mucositis is often not classi- fied as severe and also not taken seri- ously by the patient. Based on various examinations, prevalence for peri-implantitis var- ies significantly between 2 and 58 per cent of all implants (Koldsland et al.). According to a Cochrane report pub- lished in 2011, there is insufficient evidence for known peri-implantitis treatments. More research in this The authors experience regarding their preferred protocol for peri- implantitis treatment is presented step by step in the following clini- cal case. The Implacure® (MedTech Dental AG) peri-implantitis set and a regenerative, bio- mimetic bone re- placement material (CERASORB® M, curasan AG) were used to replace the lost bone. Surgical protocol 1. Formation and mobilisation of a mucoperiosteal flap to achieve unconstrained access to the defect area. If possible, the superstructure should be removed. 2. Careful curettage of the infected area, thorough removal of all soft- tissue adhesions on the bone. 3. Decontamination of the implant surface using various burs: both the apical part, that later will come into contact with the bone replacement material, as well as the crestal part, that later will be in contact with mu- cosa have to be cleaned. 4. Dressing of the entire exposed bone surfaces with sterile gauze and moistening of the gauze with ster- ile saline solution in order to improve its adhesion to the bone. 5. Application of a gel comprised of 37% phosphoric acid and 2% chlo- Fig. 1 Fig. 2 rhexidine onto the entire exposed implant surface in order to eliminate all remaining biofilm. 6. After two minutes, the gel is thor- oughly rinsed off with saline solu- tion and the gauze is removed. 7. Dressing the entire implant sur- face in sterile gauze. The gauze is subsequently soaked with a sodium hyaluronate/piperacillin/tazobac- tam solution, letting it set for five minutes. 8. Removal of the gauze. 9. The bone replacement material is blended with a sodium hyaluronate/ piperacillin/tazobactam solution and autologous blood taken from the defect area or PRP in a sterile con- tainer and inserted into the affected area without pressure. The defect area is subsequently covered with a resorbable collagen membrane which was previously soaked in anti- biotic solution. 10. Re-adaption of the flap and sutur- ing. Case presentation A 59-year-old patient presented to the practice complaining about mi- nor exudate at his dental implants in the anterior region (Fig. 1). Prob- ing revealed a deep circular pocket around the implants during the ini- tial examination. Mobility of the im- plants was, however, not detected. As suspected, the radiographic exami- nation confirmed an advanced peri- implantitis at the recently placed implants (Fig. 2). In accordance with the described protocol, a muco- periosteal flap was created in order to obtain full access to the severe four-wall defect (Fig. 3). The implant surface was mechani- cally cleaned with diamond-coated Fig. 8 ÿPage C3 Fig. 3 Fig. 4 Fig. 5