peri-implantitis issue - jiacd41 treatment of peri-implantitis using open flap debridement and...

The Journal of Implant & Advanced Clinical Dentistry

Volume 5, No. 6 JuNe 2013

Peri-ImplantitisIssue

PROVEN.PREFERRED.

CONSISTENT.

TRUSTWORTHY.PREDICTABLE.

RELIABLE.

CERTAIN.GUARANTEED.POSITIVE.

TESTED.

COST-EFFECTIVE.

EXCELLENT.A GAME CHANGER. RELEVANT. GREAT. USER-FRIENDLY.

IDEAL.TIME-

SAVING.

REMARKABLE.

EFFECTIVE.SUCCESSFUL.

DEPENDABLE.STABLE.

SURE.

OUTSTANDING.

osteogenics.com | 888.796.1923

Big words for such a small membrane, but Cytoplast™ TXT-200 Singles

have lived up to those words from your colleagues for more than 15 years.

“

Blue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affi liated with Nobel Biocare, Straumann AG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of Nobel Biocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental.

*activFluor® surface has a modifi ed topography for bone apposition on the implant surface without additional chemical activity.

**U.S. and Canada. Minimum purchase requirement for some countries.

Order online at www.blueskybio.com

CompatibilityInnovation Value

Shipping World Wide

X Cube Surgical Motor with Handpiece - $1,990.00Including 20:1 handpiece, foot control pedal, internal spray nozzle, tube holder, tube clamp, Y-connector and irrigation tube

Bio ❘ Sutures All Sutures 60cm length, 12/boxPolypropylene - $50.00

PGA Fast Resorb - $40.00

PGA - $30.00

Nylon - $20

Silk - $15

Bio ❘ TCP - $58/1ccBeta-Tricalcium Phosphate – available in .25 to 1mm and 1mm to 2mm

Bio ❘One StageStraumannCompatible

Bio ❘ Internal HexZimmerCompatible

Bio ❘ TrilobeNobelCompatible

Bio ❘ZimmerCompatible

Bio ❘NobelCompatible

Bio ❘StraumannCompatible

BlueSkyBio Ad-JIACD Dec.indd 1 10/26/11 12:59 PM

The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 5, No. 6 • JuNe 2013

Table of Contents

Blue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affi liated with Nobel Biocare, Straumann AG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of Nobel Biocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental.

*activFluor® surface has a modifi ed topography for bone apposition on the implant surface without additional chemical activity.

**U.S. and Canada. Minimum purchase requirement for some countries.

Order online at www.blueskybio.com

CompatibilityInnovation Value

Shipping World Wide

X Cube Surgical Motor with Handpiece - $1,990.00Including 20:1 handpiece, foot control pedal, internal spray nozzle, tube holder, tube clamp, Y-connector and irrigation tube

Bio ❘ Sutures All Sutures 60cm length, 12/boxPolypropylene - $50.00

PGA Fast Resorb - $40.00

PGA - $30.00

Nylon - $20

Silk - $15

Bio ❘ TCP - $58/1ccBeta-Tricalcium Phosphate – available in .25 to 1mm and 1mm to 2mm

Bio ❘One StageStraumannCompatible

Bio ❘ Internal HexZimmerCompatible

Bio ❘ TrilobeNobelCompatible

Bio ❘ZimmerCompatible

Bio ❘NobelCompatible

Bio ❘StraumannCompatible

BlueSkyBio Ad-JIACD Dec.indd 1 10/26/11 12:59 PM

11 Excess Cement and Peri-implant Disease Donald P. Callan, Charles M. Cobb

21 Iatrogenic Peri-Implantitis: Treatment and One to Two Year Follow up Pradeep Adatrow, George Hilal, David Cagna, Paul Bland

ACE Surgical Supply Co., Inc • 1034 Pearl Street, Brockton, MANobelBiocare™ and NobelReplace® are trademarks of Nobel Biocare Services AG. • Zimmer® and Tapered Screw-Vent® are registered trademarks of of Zimmer Dental, USA

Familiar Confidence.The infinity System allows you to place our implants with the familiar confidence you get from your existing system.

Sensible Compatibility. Designed to work with your existing implant system, you have the flexibility to use your existing surgical drills, drivers, and prosthetics to place and restore the implant.

Endless Opportunities.You will notice one difference with the infinity Implant...pricing. We are committed to delivering a compatible implant at pricing that creates significant opportunities for both you and your patients.

Give us a call today to experience infinity!

acesurgical.com 1.800.441.3100

A L L N E W F R O M

E x p a n d a b l E b O n E G r a F t i n G C O m p O S i t E

Compressed

Expanded

NuOssXC™ the latest development in natural bone substitutes:• Supports bone growth in periodontal and oral maxillofacial defects. • Is a composite grafting material comprised of mineralized de-proteinated bovine granules

and purified type I bovine collagen.• When placed into a bleeding site, the material expands to a predetermined size and shape.• Available in sinus form and socket form, which is supplied pre-loaded in a delivery syringe.Features and Benefits:• Expanding composite material allows for placement in a compressed form with self-expansion

to fill the entire defect upon hydration.• Simple implantation technique.• Composite nature of the material enhances graft stability and minimizes particulate migration.• Optimizes spacing between particulate to allow for bone ingrowth .Expansion time: Immediately upon contact with blood source or by hydration with sterile saline after implantation.

NuOss XC™ Socket NuOss XC™ Sinus

each infinity implant only

tri-camSurgically compatible with NobelBiocare™ NobelReplace®

internal hexSurgically compatible with Zimmer® Tapered Screw-Vent®



Table of Contents

31 Bone Regeneration Around a Failing Implant in an Osteopetrotic Patient: A Clinical Case Report Eric G. Driver, Simon R. MacNeill, Charles M. Cobb

41 Treatment of Peri-implantitis Using Open Flap Debridement and Iodine Solution with Autogenous Bone Graft: A Case Report Miki Taketomi Saito, Mauro Pedrine Santamaria, Karina Gonzales Silvério, Enilson Antônio Sallum

Click For Our Quantity

Discount Options

www.exac.com/QuantityDiscountOptions

© 2

012

Exac

tech

, Inc

.

Oralife is a single donor grafting product processed in accordance with AATB standards as well as state and federal regulations (FDA and the states of Florida, California, Maryland and New York). Oralife allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc.1. Data on file at Exactech. 2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96. 3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and

other growth factors in demineralized bone matrix. Orthopedics. 2004 Jan;27(1 Suppl):s161-5.

What’s Your Sign?

www.exac.com/dental1-866-284-9690

• Cost-effectivegraftingmaterial

• Validatedtomaintainosteoinductivityand biomechanical integrity1

• MixtureofDBMwithmineral-retained cortical and cancellous chips, processed in a manner to retainthenaturally-occuringgrowthfactors(BMP)andbeaconductivelattice – all in one product1,2,3

NEW Oralife Plus Combination Allograft available now!

MEET OUR

PlusA QUALITY COMBINATION



PublisherLC Publications

DesignJimmydog Design Group www.jimmydog.com

Production ManagerStephanie Belcher 336-201-7475 • [email protected]

Copy EditorJIACD staff

Digital ConversionNxtBook Media

Internet ManagementInfoSwell Media

Subscription Information: Annual rates as follows: Non-qualified individual: $99(USD) Institutional: $99(USD). For more information regarding subscriptions, contact [email protected] or 1-888-923-0002.

Advertising Policy: All advertisements appearing in the Journal of Implant and Advanced Clinical Dentistry (JIACD) must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. The publication of an advertisement in JIACD does not constitute an endorsement by the publisher. Additionally, the publisher does not guarantee or warrant any claims made by JIACD advertisers.

For advertising information, please contact:[email protected] or 1-888-923-0002

Manuscript Submission: JIACD publishing guidelines can be found at http://www.jiacd.com/author-guidelines or by calling 1-888-923-0002.

Copyright © 2013 by LC Publications. All rights reserved under United States and International Copyright Conventions. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying or any other information retrieval system, without prior written permission from the publisher.

Disclaimer: Reading an article in JIACD does not qualify the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its staff, and parent company LC Publications (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.

Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-SOM. JIACD-SOM disclaims any responsibility or liability for such material and does not guarantee, warrant, nor endorse any product, procedure, or technique discussed in JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its affiliated websites, or affiliated communications.

Conflicts of Interest: Authors submitting articles to JIACD must declare, in writing, any potential conflicts of interest, monetary or otherwise, that may exist with the article. Failure to submit a conflict of interest declaration will result in suspension of manuscript peer review.

Erratum: Please notify JIACD of article discrepancies or errors by contacting [email protected]

JIACD (ISSN 1947-5284) is published on a monthly basis by LC Publications, Las Vegas, Nevada, USA.

Click For Our Quantity

Discount Options

www.exac.com/QuantityDiscountOptions

© 2

012

Exac

tech

, Inc

.

Oralife is a single donor grafting product processed in accordance with AATB standards as well as state and federal regulations (FDA and the states of Florida, California, Maryland and New York). Oralife allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc.1. Data on file at Exactech. 2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96. 3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and

other growth factors in demineralized bone matrix. Orthopedics. 2004 Jan;27(1 Suppl):s161-5.

What’s Your Sign?

www.exac.com/dental1-866-284-9690

• Cost-effectivegraftingmaterial

• Validatedtomaintainosteoinductivityand biomechanical integrity1

• MixtureofDBMwithmineral-retained cortical and cancellous chips, processed in a manner to retainthenaturally-occuringgrowthfactors(BMP)andbeaconductivelattice – all in one product1,2,3

NEW Oralife Plus Combination Allograft available now!

MEET OUR

PlusA QUALITY COMBINATION

Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com

Esthetiline- the complete anatomicalrestorative solution


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS


Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com

Esthetiline- the complete anatomicalrestorative solution

Callan et al

DID YOU KNOW?Roxolid implants deliver more treatment options

Roxolid is optimal for treatment of narrow interdental spaces.

Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA

Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area.

www.straumann.us

Callan et al

Background: Among the dental consumer population, dental implants are an increasingly popular option for replacing teeth and restor-ing function. Since implants became a common modality, assessments of their success have included improved appearance, restored ability to eat, and longevity of placement. By and large, the most appealing appearance drives the choice of dental implants for the patient. However, patients and dentists should be aware of pos-sible complications that could affect the patient’s oral and systemic health, even when excellent esthetic results are achieved. This article dem-onstrates an excellent esthetic result even with the presence excess subgingival cement fol-lowing placement of a fixed prosthesis associ-ated with no clinical signs of inflammation but with radiographic signs of peri-implant disease.

Methods: Three healthy females sought tooth replacement with dental implants. There were no contraindications for the placement of den-tal implants and proper surgical protocols were followed as specified by the implant manufac-turer. The implants were restored three and one half months post surgery with a cemented crown.

Three different restorative dentists were utilized for the three patients. Occlusal evaluations and adjustments were performed for each patient along with proper home care instructions as needed.

Results: The first recall visit showed no clini-cal signs of inflammation and all patients reported no discomfort, bleeding during routine home care procedures, normal function and accept-able esthetics. A radiograph was taken on each patient. Radiographic bone loss was noted on the mesial or distal coronal portion of the implant body. Mucogingival flaps were elevated on each implant and subgingival dental cement was noted on the three dental implants. The cements were not visible on the radiographs. Conclusion: When restoring dental implants, the restorative dentist must exert extreme care to remove all dental cement about the implant body. In the cases presented in this report, although the restorations displayed acceptable esthetics and normal function with no clinical signs of inflamma-tion or patient discomfort, excess cement appeared to create a localized inflammatory response that resulted in bone loss about the dental implants.

Excess Cement and Peri-implant Disease

Donald P. Callan, BS, BA, DDS1 • Charles M. Cobb, DDS, PhD2

1. Private Practice limited to Periodontics, Little Rock, Arkansas, USA2. Professor Emeritus, Department Of Periodontics, School Of Dentistry, University of Missouri-Kansas City,

Kansas City, Missouri, USA

Abstract

KEY WORDS: Dental implants, dental restoration, cement, inflammation


12 • Vol. 5, No. 6 • June 2013

Callan et al

INTRODUCTIONAmong the dental consumer population, dental implants are an increasingly popular option for replacing teeth and restoring function from the missing teeth. Since implants became a com-mon modality, assessments of their success have included improved appearance, restored abil-ity to eat, and longevity of placement and main-taining a healthy environment. By and large, appealing appearance drives the choice of den-tal implants for the patient. However, patients and dentists should be aware of possible com-plications that could affect the patient’s oral and systemic health, even when excellent esthetic results are achieved. Local inflammation associ-ated with teeth and dental implants is a signifi-cant clinical phenomenon and may pose systemic concerns through the inflammatory response of the host. The occurrence of infection, inflamma-tion, and bone loss about teeth and implants will often compromise long-term prognosis, esthet-ics, function, oral health, and, if extensive, will ultimately lead to tooth and implant failure.1-4

Some researchers and implant companies have indicated the crestal bone loss around den-tal implants is a normal occurrence. Local bone loss about teeth and dental implants is the result of inflammation. Gingivitis and periodontitis are both caused by a diverse population of oral bacte-ria with similarities of microbial populations exist-ing between implants and natural teeth. Many of the same periodontal pathologic bacteria have been isolated from implants, thus conclud-ing that Periodontitis and Peri-Implantitis are one in the same5 and may have systemic concerns.

Implant supported restorations may be retained by either dental retrievable screws or cements.6,7 Attaching the restoration to the implant body with

a screw may have problems including loosen-ing of the screw, fracture of the screw, esthetic concerns, increased cost, and a complex res-toration.8-10 Utilizing dental cements may allevi-ate most of these problems.11 Applying dental cements on the abutment of dental implant resto-rations is much the same as crown restorations on natural teeth. Little information has been provided in the literature regarding the potential problems of excess cement being retained subgingivally about dental implants after the completion of the res-toration.12-14 This report documents three cases illustrating complications that may arise following the cementation of dental crowns on osseointe-grated dental implants. One possible problem appears to be the inflammatory response as cre-ated by not removing excess subgingival cement.

MATERIALS AND METHODS

Three healthy partially edentulous patients aged 36 to 56 years were evaluated after the place-ment of dental implants and the final cementation of dental prostheses. All patients were in good health and had no contraindications for the place-ment of dental implants. Following completion of oral hygiene evaluation, oral hygiene instructions, and necessary periodontal therapy, one dental implant was placed in each patient according to the manufacturer’s protocol. All three patients were allowed to heal for a minimum of 3½ months to a maximum of 4 ½ months after implant place-ment. After implant placement, a second surgical procedure was performed to expose the implants to the oral environment for prosthetic connec-tion. During the second stage surgery, no bone loss was noted at the about the neck of any of the implants. Oral hygiene instruction was reviewed with each patient before and after implant place-


Callan et al

ment and at the second surgical procedure. There were no complications following the first and sec-ond surgeries and all three patients healed as anticipated. Radiographs were taken prior to implant placement and 3½ months after implant placement. All radiographs showed no bone loss. After healing of the second surgery, the soft tis-sues appeared normal in color, texture, form, and the patients reported little to no discomfort.

The patients were referred back to the restor-ative dentist for the completion of the restor-ative procedures. The cements were selected by each individual restorative dentist as to their preference and were used according to the manufacturer’s specifications. After cementa-tion of the prosthesis, the restorative dentists attempted to remove excess cement about the abutment/prosthesis in the usual fashion.

Six months following the prosthetic procedures, the soft tissues about the implants appeared nor-mal in color, texture, and form (figure 1) and all patients reported no discomfort. Upon probing with a periodontal probe (Williams markings), the

pocket depths ranged from 6 to 7 mm in depth and there were no bleeding points. Radiographs revealed bone loss on the mesial or distal of each implant being evaluated (figure 2). The pocket depths were noted on the same side as the radio-graphic bone loss. Mucoperiosteal flaps were elevated about each implant (figures 3,4). Den-tal cement was noted at the most coronal area of each implant that showed radiographic bone loss. On one of the patents, the bone loss so severe the implant was removed while removing the gran-ulation tissue and the excess cement (figure 5).

To verify the identity of the material, a biopsy was taken from one of the patients and submit-ted to the oral pathology department at the Uni-versity of Missouri at Kansas City for histological, scanning electron microscopy (SEM), Secondary Electron Imaging, and Electron Dispersion X-ray Analysis (EDS) evaluations. Four particles of a solid hardened material were chipped from the implant abutment/prosthesis interface and placed in a 10% neutral buffered formalin solution. A soft tissue biopsy consisting of gingiva and granula-

Figure 1: Six months after prosthetic procedures, note the soft tissues about the implants appearing normal in color, texture, and form.

Figure 2: Radiograph revealed bone loss on the mesial of the implant being evaluated. No cement was noted on the radiograph.

14 • Vol. 5, No. 6 • June 2013

Callan et al

tion tissue was procured circumferentially from around the implant prior to removal of the implant from the alveolus (figure 5). The soft tissue biopsy was also placed in a 10% neutral buffered for-malin solution and later processed for routine light microscopy, i.e., sectioned at 7µm thickness and stained with hematoxylin and eosin (H & E).

Following fixation in the buffered formalin solution, the solid particles were washed in ice-

cold 0.1 M cacodylate buffer at pH 7.4 for three cycles of 2 hours each. The specimens were then allowed to dry and dehydrate in a dissector for 24 hours. Following drying/dehydration the specimens were affixed to aluminum stubs and sputtered coated with a carbon film. The coated specimens were then examined with the aid of a Philips field emission SEM (model XL-30 ESEM-FEI, Philips Electronic Instruments, Inc., Mahwah, NJ, USA). In addition to routine morphology, the particles were examined by: 1) x-ray microanaly-sis using electron dispersive x-ray spectroscopy (a.k.a. EDS; Bruker AXS Microanalysis, Ewing, NJ, USA); 2) secondary electron imaging; and 3) x-ray mapping, the latter two procedures using 15 kV accelerating voltage at a 10 mm working distance.

RESULTSSoft Tissue Light MicroscopyHematoxylin and Eosin (H&E) stained soft tissue sections revealed a moderately dense fibrosis sur-rounding numerous embedded foreign material (figure 6). The connective tissues were infiltrated

Figure 3: Excess cement was noted about the apical portion of the prosthetic margin.

Figure 4: Excess cement was noted about the apical portion of the prosthetic margin.

Figure 5: Implant as shown in figure 1 was lost during the removal of the excess cement about the apical portion of the prosthetic margin and on the implant body.


Callan et al

by chronic inflammatory cells dominated by lym-phocytes and plasma cells. The foreign material was particulate and presented two different stain-ing affinities. There were particles that exhibited an overt affinity for hematoxylin, resulting in a deep purple staining pattern while other particles exhib-ited a slight affinity for the hematoxylin (figure 7) that resulted in a faint purple-pink staining pattern. Lastly, isolated islands of embedded microbial biofilm were noted near the tissue surface adja-cent to the presumed peri-implant pocket area.

SEM and Secondary Electron ImagingAll particles were characterized by a relatively amorphous surface topography. Under routine SEM examination, the surface appeared rela-tively smooth except for the presence of localized deposits of loosened debris. The primary sur-

face features were induced craze lines (crack-ing), a result of the dehydration process. There was no evidence of soft tissue adherence (figures 8,9). Secondary electron imaging of the same specimen revealed a more roughened and irreg-ular surface topography. However, both routine SEM and secondary electron imaging provided sufficient morphologic evidence to allow differ-entiation of the material from tooth root or bone.

Electron Dispersion X-ray Analysis (EDS)The EDS scan of the particle surface showed peaks of varying intensities conforming to the following elements: low peaks for sodium and potassium; moderate peaks for car-bon and sulfur; moderately high peaks for oxygen, calcium, aluminum, and phospho-rus; and a high peak for silicon (figure 10).

Figure 6: H & E stained section from the soft tissue biopsy embedded particles of solid material that are heavily hematoxylinophilic (arrow) adjacent to other solid particles that exhibit a mixed eosinophilia and low affinity for hematoxylin (forked arrow). The blue-purple area in the upper center of the specimen represents an impacted mass of bacteria (star). Note the extensive fibrosis surrounding the solid particles. Original magnification of 100x.

Figure 7: Higher magnification of area of interest from figure 6 showing the amorphous structure of the solid particles. Again, note the fibrosis with an interspersed infiltrate of chronic inflammatory cells. Original magnification of 200x.

16 • Vol. 5, No. 6 • June 2013

Callan et al

Figure 8: Routine SEM of solid particle removed from the implant collar/prosthetic abutment interface. Surface features consisted of dehydration induced crazing and loosened debris. Bar = 500 µm at an original magnification of 40x.

Figure 9: Secondary electron image of same specimen shown in figure 8 indicating a more undulating and roughened surface topography than can be seen using routine SEM imaging techniques. Bar = 500 µm at an original magnification of 40x.

Figure 10: EDS scan of surface of specimen pictured in figures 8 & 9 showing peaks that identify the presence of the following elements (left to right): carbon, calcium, oxygen, sodium, aluminum, silicon, phosphorus, sulfur, potassium, and a second calcium peak.


Callan et al

X-ray MappingX-ray mapping confirmed the EDS observa-tions by revealing a consistently uniform and regular pattern of distribution of calcium, phos-phorus, silicon, aluminum and sulfur (figure 11) on the surfaces of the various particles.

DISCUSSIONThe surgical dentists and three restorative den-tists involved with these cases had extensive implant experience. The restorative dentists were surprised to see the amount of bone loss as indicated by the radiographs at the six month

appointment. All three dentists stated they had no indication the bone loss was occurring or the etiology of the bone loss prior to viewing the radiographs. After advising the patients of the bone loss about the implants, the patients agreed to exploratory surgery to determine the cause of bone loss to correct the problem, if possible. During the exploratory surgery on all 3 implant cases, excess cement was noted about the api-cal portion of the prosthetic margins (figures 3-5).

Histologic evaluation of the biopsy sample revealed solid globular masses, surrounded by fibrosis and a mononuclear inflammatory cell

Figure 11: X-ray mapping of the surface of the same specimen shown in Figures 8 & 9. Note the uniform distribution of calcium (Ca K), phosphorus (P K), aluminum (Al k), silicon (Si K), and sulfur (S K). The last image is a routine SEM to show the surface morphology that corresponds to the location and distribution of the various elements.

18 • Vol. 5, No. 6 • June 2013

Callan et al

infiltrate consistent with a low-grade chronic inflammation. Both the morphology and multiple staining intensities were consistent with residual dental cement. Interestingly, the biopsy exhib-ited several areas of embedded masses of bac-teria as well. The overall impression suggests the high probability of residual cement and bac-terial biofilm having been forced into adjacent gingival tissues during instrumentation of the peri-implant sulcus and/or periodontal pocket.

When viewed collectively, the various meth-ods used to examine the hard particles confirm the presence of a non-biologic material, most likely residual dental cement. Routine and sec-ondary electron imaging were used to provide high-resolution images of the surface morphol-ogy to rule out biologic origins that might include bone or residual tooth structure (figures 8,9). Furthermore, the morphology appears inconsis-tent with synthetic bone grafting material, such as hydroxyapatite granules or bioactive glass.

EDS is an analytical technique used for the qualitative elemental analysis or chemical characterization of a sample (figure 10). The high silicon peak, when coupled with the pres-ence of aluminum, is conclusive evidence that the specimen was of non-biologic origins. The uniform distribution of the silicon and alumi-num within the specimen, as shown by the x-ray mapping technique (figure 11), is further support for the presence of dental cement.

CONCLUSIONThis limited study demonstrates that dentists should be aware of the potential problems with cementing permanent restorations with subgingi-val margins on dental implants. Residual subgin-gival cement appears to establish inflammatory

conditions that resorb bone about the dental implants. It is recommended that clinicians uti-lize radiopaque cement to allow for radiographic visualization before dismissing the patient. ●

Correspondence:Dr. Donald P. Callan10319 West MarkhamSuite 300Little Rock, Arkansas 72205e-mail: [email protected]

Disclosure:The authors report no conflicts of interest with anything mentioned in this article.

References1. Heydenrijk K, Meijer HJ, van der Reijden WA, Raghoebar GM, Vissink A,

Stegenga B. Microbiota around root-form endosseous implants: A review of the literature. Int J Oral Maxillofac Implants 2002; 17:829-838.

2. Hultin M, Gustafsson A, Hallstrom H, Johansson LA, Ekfeldt A, Klinge B. Microbiological findings and host response in patients with peri-implantitis. Clin Oral Implants Res 2002; 13:349-358.

3. Rutar A, Lang NP, Buser D, Burgin W, Mombelli A. Retrospective assessment of clinical and microbiological factors affecting periimplant tissue conditions. Clin Oral Implants Res 2001; 12:189-195.

4. van Winkelhoff AJ, Goene RJ, Benschop C, Folmer T. Early colonization of dental implants by putative periodontal pathogens in partially edentulous patients. Clin Oral Implants Res 2000; 11:511-520.

5. Callan, DP, Cobb, CM and Williams KB. DNA Probe Identification of Bacteria Colonizing Internal Surfaces of the Implant-Abutment Interface: A Preliminary Study; J Periodontol 2005; 76(1):115-120.

6. Weber HP, Kim DM, Ng MW, Hwang JW, Fiorellini JP. Peri-implant soft-tissue health surrounding cement- and screw-retained implant restorations: a multi-center, 3-year prospective study. Clin Oral Implants Res 2006; 17(4):375-379.

7. Squier RS, Agar JR, Duncan JP, Taylor TD. Retentiveness of Dental Cements Used with Metallic Implant Components. Int J of Oral Maxillofac Implants 2001; 16:793-798.

8. Jent T, Linden B, Lekholm U. Failures and Complications in 127 Consecutively Placed Fixed Partial Prostheses Supported by Branemark Implants. From Prosthetic Treatment to First Annual Checkup. Int J of Oral Maxillofac Implants 1992; 7:40-44.

9. Carlson B, Carlsson G. Prosthetic Complications in Osseointegrated Dental Implant Treatment. Int J of Oral Maxillofac Implants 1994; 9:90-94.

10. Kallus T, Bessing C. Loose Gold Screws Frequently Occur in Full Arch Fixed Prostheses Supported by Osseointegrated Implants after Five Years. Int J of Oral Maxillofac Implants 1994; 9:169-178.

11. Hebel K, Gajjar R. Cement Retained Versus Screw Retained Implant restorations. Achieving Optimal Occlusion and Esthetics in Implant Dentistry. J Prosthet Dent 1997; 77:28-35.

12. Agar JR, Cameron SM, Hughbanks JC, Parker MH. Cement Removal Restorations Luted to Titanium Abutments with Simulation Subgingival Margins. J Prosthet Dent 1997; 78:43-47.

13. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with excess cement around crowns on osseointegrated implants: a clinical report. Int J of Oral Maxillofac Implants 1999; 14(6):865-868.

14. Gapski R, Neugeboren N, Pomeranz AZ, Ressner MW. Endosseous Implant Failure Influenced by Crown Cementation: A Clinical Case Report. Int J of Oral Maxillofac Implants 2008; 23:943-946.

Callan et al

For more information, contact BioHorizonsCustomer Care: 1.888.246.8338 or shop online at www.biohorizons.com

SPMP12245 REV A SEP 2012

make the switch

The Tapered Plus implant system offers all the great benefits of BioHorizons highly successful Tapered Internal system PLUS it features a Laser-Lok treated beveled-collar for bone and soft tissue attachment and platform switching designed for increased soft tissue volume.

Laser-Lok® zoneCreates a connective tissue seal and maintains crestal bone

platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification

Autoclavable LED's Progressive Pedal Controlled Power

- Three times more power than PIEZOTOME1! (60 watts vs 18 watts of output power in the handpiece) Procedures are faster than ever, giving you a clean and effortless cut- NEWTRON LED and PIEZOTOME2 LED Handpieces output 100,000 LUX!- Extremely precise irrigation flow to avoid any risk of bone necrosis- Selective cut: respect of soft tissue (nerves, membranes, arteries) - Less traumatic treatment: reduces bone loss and less bleeding- 1st EVER Autoclavable LED Surgical Ultrasonic Handpieces - Giant user-friendly 5.7" color touch-control screen - Ultra-sharp, robust and resistant tips (30+ Surgical & 80+ Conventional)

PIEZOTOME2 and IMPLANT CENTER2

- I-Surge Implant Motor (Contra-Angles not included)- Compatible with all electric contra-angles (any ratio)- Highest torque of any micro-motor on the market- Widest speed range on the market

All the benefits of the PIEZOTOME2...PLUS...

ACTEON North America 124 Gaither Drive, Suite 140 Mount Laurel, NJ 08054Tel - (800) 289 6367 Fax - (856) 222 4726

www.us.acteongroup.com E-mail: [email protected]

..

.

Padatrow et al

Background: Peri-implantitis may be associated with a number of variables ranging from patient related to iatrogenic factors. Peri-implant muco-sal tissues may be more vulnerable to plaque induced inflammatory changes due to differences in gingival attachment between implants and natu-ral teeth. Local factors that encourage bacterial growth and reduce implant integration should be considered when diagnosing and treating inflam-matory lesions identified around restored implants.

Methods: Two patients presented with clini-cal and radiographic signs consistent with infection adjacent to restored dental implants. During surgical therapy of the affected areas, dental cement was discovered adhering to abutment and implant surfaces. Management involved thorough debridement of granuloma-tous tissue, removal of subgingival cement, implant detoxification, and regenerative therapy.

Results: Peri-implant clinical signs of infec-tion abated and radiographic evidence of bone regeneration occurred following sur-gical intervention on the affected implants. Patients were placed on three month main-tenance schedules. Clinically detectable implant stability was discernable one and two years following active patient therapy.

Conclusions: Factors that promote peri-implant bacterial retention can be detrimen-tal to long term success. Excess subgingival cement in close approximation to implant and abutment surfaces appeared to be a signifi-cant causative factor in the two cases pre-sented in this article. Cement removal during surgical intervention, decontamina-tion of involved surfaces, and bone grafting resulted in a clinically stable outcome over the two years of post-operative maintenance.

Iatrogenic Peri-Implantitis: Treatment and One to Two Year Follow up

Pradeep Adatrow, DDS, MSD, MPH1 • George Hilal, DMD, MDS2 David Cagna, DDS, MS3 • Paul Bland, DDS4

1. Director, Pre-Doctoral Periodontics, Department of Periodontology, University of Tennessee College of Dentistry

2. Private Practice, Memphis, TN, USA

3. Director, Graduate Prosthodontics, Department of Restorative Dentistry, University of Tennessee College of Dentistry

4. Chair, Department of Periodontology, University of Tennessee

Abstract

KEY WORDS: Peri-implantitis, iatrogenic causes, peri-implantitis treatment


22 • Vol. 5, No. 6 • June 2013

Adatrow et al

IntRODuCtIOn:Inflammatory lesions that develop adjacent to implants are collectively referred to as “peri-implant diseases” and may include peri-implant mucositis and peri-implantitis. Peri-implantitis is characterized by the presence of inflamma-tion in the mucosa along with loss of support-ing bone.1 The frequency of peri-implantitis has been reported in many long term studies. However, due to variation in assessment meth-odology, reliable consensus in the literature is unavailable. Nevertheless, a recent system-atic review of cross sectional and longitudinal studies with ≥ 50 subjects and ≥ 5 years of occlusal function, reported that peri-implanti-tis was identified in 12-46% of implant sites.2

Peri-implantitis is often asymptomatic and typically detected during routine recall examina-tions. Several clinical indicators used to evalu-ate periodontal health have also been used to evaluate peri-implant health, including assess-ment of oral hygiene, peri-implant marginal tissues, and the bone implant interface. Rec-ommended diagnostic parameters for assess-ing peri-implant health are: probing depth measurements using conventional probing with a light probing force (0.25N), presence or absence of bleeding or suppuration on probing using a light probing force (0.25N), and radio-graphic assessment of supporting bone levels.1

A number of patient-related and implant-related factors may contribute to the devel-opment and progression of peri-implantitis. Compelling evidence is available for increased susceptibility to peri-implantitis in patients who smoke, have a history of periodontal dis-ease, and exhibit poor oral hygiene.3 The impact of IL-1 positive genotype and diabetes

must also be considered and specific implant design and surface characteristics may also contribute to the risk and progression of peri-implantitis.3 Failure to remove excess cement following placement of cement-retained pros-theses may also contribute to the development and progression of peri-implantitis. This report documents two patients in whom excess sub-gingival cement was associated with signs of peri-implantitis. Clinical management strategies and long term therapeutic results are discussed.

CASE REpORtS:Case 1:A 64 year old partially edentulous female was referred for evaluation of a draining fistula adjacent to implants #28 and #29. Her medi-cal history was unremarkable. An implant in area #30 had been in place for 14 years, and the implants in area #28 and #29 had been in place for 4 years. Several months following the surgical placement of implants #28 and #29, the patient complained to her general dentist of swelling and a bad taste in her mouth. The gen-eral dentist removed the crowns and attempted

Figure 1: Initial presentation with abscess.


Aadatrow et al

non-surgical therapy around the implants. The peri-implant infection persisted and the gen-eral dentist referred the patient for consultation. Upon clinical examination (figure 1), a fluctuant swelling was noted on the buccal mucosa inter-proximal to implants # 28 and 29, with bleeding and suppuration evident on probing. Probing depths ranged from 4-8mm around implant #28 and 8-9 mm around implant #29. A periapical radiograph revealed horizontal bone loss around

implant #28 and vertical bone loss around implant #29 (figure 2). The decision was made to perform an exploratory surgical procedure to investigate possible etiologic factors and determine the prognosis of involved implants.

Under local anesthesia, crestal and sul-cular incisions were made and full thickness mucoperiosteal flaps elevated around the implants. A thin white film was found adhering to the mesial aspect of implant #29, extend-

Figure 2: Initial radiograph. Figure 3: Flap elevated showing cement film on the mesial of Implant in area of #29.

Figure 4: Implants debrided and detoxified. Figure 5: Bio-Oss Bovine bone graft placed around the implants.

24 • Vol. 5, No. 6 • June 2013

Adatrow et al

ing from the implant abutment interface to the first thread (figure 3). On close examination, the white film was determined to be glass iono-mer cement. The surgical area was thoroughly debrided and degranulated. Plastic curettes and a rotary rubber cup with pumice were used to completely remove the glass ionomer cement from the implant surface. The implant surface was then decontaminated using H2O2 , chlorhexidine 0.12%, and 50mg/ml tetracy-cline applied for 2 minutes. Decortications were accomplished on the peri-implant bone and Bio-Oss®, bovine cortical bone particles (Osteohealth, Shirley, NY) were placed in the osseous defect (figures 4,5). Two holes cor-responding to the implants abutments were made through a 20mm x 30mm Biomend® col-lagen membrane (Zimmer Dental, Carlsbad, CA) and the membrane was placed over the abutments to cover the bone graft material. The flaps were replaced and sutured with 4-0 Vicryl® sutures (Ethicon, New York, NY) and the patient was placed on 500-mg Augmentin (GlaxoSmithKline, Pittsburg, PA) three times a day for 7 days and a 0.12 % chlorhexidine rinse.

Post-operative healing was uneventful. Implants/abutments remained unrestored dur-ing the healing period. At six months, firm keratinized gingiva was identified around both implants and radiographs suggested bone fill associated with implant #29 (figures 6, 7). New crowns were fabricated and deliv-ered. The patient was instructed on oral hygiene techniques and placed on a 3-month maintenance protocol. At 24 months fol-lowing surgical intervention, the implant was clinically determined to be functioning well without signs of recurrent infection (figure 8).

Figure 6: Clinical Presentation at 6 months post surgery.

Figure 7: Radiographic Presentation at 6 months post surgery.

Figure 8: Radiographic presentation at 24 months.


Adatrow et al

Case 2:A 50-year-old partially edentulous female pre-sented to the clinic complaining of pain in the mandibular right posterior sextant. Her medi-cal history was positive for Type II Diabetes with the condition being well controlled with oral hypoglycemic medications. She had an implant placed and restored in the area #30 one year ago. She reported developing a swelling around the implant about 4 months prior, which then dis-appeared after a only few days. Upon examina-tion, probing depths ranging from 7-10mm with bleeding and suppuration were noted. Radio-graphic examination revealed severe vertical bone loss adjacent to the implant (figure 9). Inci-sion and drainage of the fluctuant mass was performed and the patient was placed on 500 mg Augmentin (GlaxoSmithKline, Pittsburg, PA) three times per day and 0.12% chlorhexidine mouth rinse for 7 days. Ten days later, heal-ing progressed with minimal complications.

A determination was made to surgically explore the area of concern and attempt bone regeneration around the implant. Upon pre-operative removal of the implant crown, a white material film was noted adhering to the apical aspect of the abutment along the implant-abut-ment interface. Closer examination revealed that the white material was glass ionomer cement (figure 10). A full thickness mucoperi-osteal flap was accomplished local anesthe-sia. Upon flap reflection, all granulation tissue was removed and the implant was decontami-nated using H2O2 , chlorhexidine 0.12%, and 50mg/ml tetracycline applied for 2 minutes. Decortications were made in the peri-implant bone and Bio-Oss® bovine cortical bone par-ticles (Osteohealth, Shirley, NY) were placed

Figure 9: Initial radiographic presentation.

Figure 10: Cement adhering to the abutment.

Figure 11: Immediate post surgical radiographic presentation.

26 • Vol. 5, No. 6 • June 2013

Adatrow et al

in the osseous defect. A hole correspond-ing to the center of the implants was made on a Biomend® collagen membrane (Zimmer Dental, Carlsbad, CA) and the membrane was placed over the implant using a healing abut-ment to secure the membrane in place (fig-ure 11). The flaps were replaced and sutured with Vicryl® sutures (Ethicon, New York, NY).

Post-operative healing was unevent-ful and the implant remained unrestored dur-ing the healing period. Six months after surgery, firm keratinized gingiva surrounded the implant and radiographs suggested suc-cessful bone fill (figure 12). Clinically there were no signs of peri-implant infection and probing depths decreased to 3-4 mm. At this point, the original abutment and implant crown were replaced. The access opening was filled with flowable light cure composite and occlu-sal adjustments were completed. The patient was instructed in oral hygiene techniques and was placed on a 3 month maintenance pro-tocol. At 14 months following treatment the implant was determined to be functioning well without signs of recurrent infection (figure 13).

DISCuSSIOnAttachment of peri-implant tissues to implant and abutment surfaces occurs by junctional epithe-lium mediated through basal lamina and hemides-mosomes.4 In contrast to the dento-gingival unit, there are no connective tissue fiber insertions into the implant surface and connective tissue fiber orientation is predominantly parallel to the implant surface.5 Coronally, connective tissue fiber orientation is circumferential and it exhib-its a lower degree of vascularization compared to periodontal attachment.6 It has been theo-rized that these differences between peri-implant and dento-gingival tissues render the former more susceptible to plaque induced inflamma-tion. The peri-implantitis cases identified and managed in this article were characteristically rapid in development and progression, and may have been a pathologic response to residual subgingival cement serving as a local plaque retentive factor at the bone-implant interface.

Treatment of peri-implantitis may include non-surgical and surgical phases. Non-surgical ther-apy consists of mechanical debridement using ultrasonic or laser devices, either alone or com-

Figure 12: Radiographic presentation at 6 months. Figure 13: Radiographic presentation at 14 months.


Adatrow et al

bined with antiseptic and/or antibiotic agents. Surgical intervention may involve either resective or regenerative techniques. To date, no meth-odology has been established as the gold stan-dard for the treatment of peri-implantitis. Based on the Consensus Statement of the Sixth Euro-pean Workshop on Periodontology,1 non-surgical therapy for peri-implantitis is unpredictable. Nev-ertheless, the use of systemic and local antibiot-ics in conjunction with non-surgical mechanical debridement has been shown effective in reduc-ing bleeding on probing and probing depths in cases of mild to moderate peri-implantitis.1 In the first case presented in this paper, even though the peri-implantitis was qualified as moderate, it did not respond to non-surgical therapy. Subse-quent surgical intervention revealed the apparent etiology and removal of residual cement success-fully established peri-implant tissue health. In the second case reported in this paper, the patient presented with peri-implantitis of greater sever-ity and non-surgical therapy, consisting of inci-sion/drainage and systemic antibiotic therapy followed by surgical intervention was required.

The primary objective of surgical treatment of peri-implantitis is to gain access to the implant surface for debridement and decontamination in order to facilitate resolution of inflammatory lesions. The determination of appropriate surgi-cal treatment is influenced by the amount of bone lost, the nature of the osseous defect, and the aesthetic impact of the implant in question. Sur-gical techniques used to manage peri-implant lesions are essentially modifications of surgical periodontal techniques. Peri-implant probing and bone sounding of suspected peri-implant osseous defects in conjunction with radiographic evalu-ation should be accomplished early in therapy.

This information provides a basis for determining therapeutic approach; implant removal, resec-tive surgery, and/or regenerative procedures.

Resective therapy is used to reduce pock-ets, correct negative osseous architecture, smooth rough implant surfaces (implantoplasty), and improve the dimensions and/or location of keratinized gingiva. Regenerative therapy is used to reduce pockets with the goal of regen-eration of favorable bone dimensions. A recent review,7 addressing open debridement, surface decontamination, and peri-implant regenera-tive procedures, revealed encouraging results in animals, but a paucity of data in humans. A prospective cohort receiving access surgery, implant decontamination, and systemic antibi-otics recorded favorable defect resolution for 58% of the implants treated.8 With regard to occlusive membranes, varying degrees of bone regeneration and re-osseointegration have been reported for regenerative procedures with or without the use of barrier membranes.7 In both of the cases presented in this article, regenera-tive procedures incorporated barrier membranes and favorable radiographic bone fill resulted.

COnCluSIOn:Two partially edentulous patients with restored and functional implants presented for evaluation of peri-implant tissue problems identified by the patients and their restorative dentists. Upon refer-ral, surgical access revealed subgingival cement on the implant and abutment surfaces. Removal of the cement, decontamination of the implant surface, and bone grafting resulted in resolution of the infections, reduction of probing depths, and radiographically apparent bone fill. Using a three month maintenance schedule, favorable

28 • Vol. 5, No. 6 • June 2013

Adatrow et al

post-operative results have been maintained for one to two years. An important local factor in the development of peri-implantitis in the patients treated appears to have been excess subgingi-val cement on implant and abutment surfaces. This observation underscores the need for care-ful control of luting agents and thorough supra- and subgingival removal of excess cement when placing cement-retained crowns on implants. ●

Correspondence:Pradeep Adatrow, DDS, MSD, MPH875 Union Ave, C 312Department of PeriodontologyUniversity of Tennessee College of DentistryMemphis, TN- 38163Phone: 901-448-4756Fax: 901-448- 6751Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References:

1. Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol. Sep 2008;35(8 Suppl):282-285.

2. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol. Sep 2008;35(8 Suppl):286-291.

3. Heitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol. Sep 2008;35(8 Suppl):292-304.

4. Listgarten MA, Lang NP, Schroeder HE, Schroeder A. Periodontal tissues and their counterparts around endosseous implants [corrected and republished with original paging, article orginally printed in Clin Oral Implants Res 1991 Jan-Mar;2(1):1-19]. Clin Oral Implants Res. Jul-Sep 1991;2(3):1-19.

5. Ruggeri A, Franchi M, Marini N, Trisi P, Piatelli A. Supracrestal circular collagen fiber network around osseointegrated nonsubmerged titanium implants. Clin Oral Implants Res. Dec 1992;3(4):169-175.

6. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems in the periodontal and peri-implant tissues in the dog. J Clin Periodontol. Mar 1994;21(3):189-193.

7. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol. Sep 2008;35(8 Suppl):316-332.

8. Leonhardt A, Dahlen G, Renvert S. Five-year clinical, microbiological, and radiological outcome following treatment of peri-implantitis in man. J Periodontol. Oct 2003;74(10):1415-1422.

ATTENTION PROSPECTIVE

AUTHORSJIACD wants

to publish your article!


For complete details regarding publication in

JIACD, please refer to our author guidelines at

the following link: http://www.jiacd.com/

authorinfo/ author-guidelines.pdf

or email us at: [email protected]

PLANMECA®

ProMax® 3D Max

Introducing thePLANMECA® ProMax® 3D

Max...

PLANMECA®

• Automatically adjusts volume sizesfor childrenWhen the child patient size is selected, the fields of view(volume sizes) and the dosage parameters areslightly reduced

• More than 36 pre-programmed targetsFrom a single tooth scan to the whole skull, theProMax 3D Max has 18 pre-programmed targets,5 adult fields of view, 5 child fields of view, and more

• Patented SCARA technology allowslimitless imaging possibilities

• Full view, open patient positioning forstanding, sitting, and wheelchair accessibility

• Space savingA small footprint and compact design make theProMax 3D Max the smallest large FOV on the market

• High resolution, flat panel technology

• Now compatible with Mac OS environment

Features• 5 selectable, single scan fields of viewMost common uses:ø5 x 5.5 cm - Individual tooth or other point of interestø10 x 5.5 cm - Mandible or maxillaø10 x 9 cm - Mandible and maxillaø10 x 13 cm - Mandible or maxilla and sinusø23 x 16 cm - Full maxillofacial image, upper or lower skull

• The smallest and largest fields of view onthe market giving the ProMax 3D Max moreversatility then any other comparableX-ray unit

• Large view, single acquisition - dual scanfor full maxillofacial and skull imagingø23 x 26 - Full skull covers the whole head and istherefore extremely useful for surgical and orthodonticprocedures, as well as TMJ, ear, sinus, and airwaystudies. Using the large volume size, it is possible togenerate a 2D cephalometric image with asingle mouse click.

For more information onPLANMECA ProMax 3D Max

please call...

1-630-529-2300or visit us on the web @www.planmecausa.com

Planmeca ProMax3dMax_JAIC102710:Layout 1 10/27/10 4:37 PM Page 1

IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!

Driver et al

Background: The exact pathogenic mechanism of osteopetrosis is unknown although a deficiency in the osteoclastic enzyme carbonic anhydrase has been observed. Osseous regeneration around failing implants remains a challenging and unpredictable problem. Thus, the pathobiology of osteopetrosis presents an additional complication when treating an osteopetrotic patient presenting with peri-implantitis requiring surgical intervention. Methods: A single case report is presented that involved a 61 year old Caucasian female with an extensive medical history that included a mild form of osteopetrosis and peri-implant disease requiring

surgical intervention due to significant bone loss. Treatment of the bony defect involved degranula-tion, implant detoxification, bone decortications, placement of a particulate osseous graft material, and coverage with a resorbable barrier membrane. Results: Radiographs taken eight months after the osseous graft procedure demonstrated sta-ble bone levels and 100% osseous regeneration. Conclusions: Regeneration of osseous sup-port around a failing implant in a patient with mild osteopetrosis is possible using the surgi-cal techniques described in this case report.

Bone Regeneration Around a Failing Implant in an Osteopetrotic Patient:

A Clinical Case Report

Eric G. Driver, DDS1 • Simon R. MacNeill, BDS, DDS2 Charles M. Cobb, DDS, MS, PhD3

1. Former resident, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City

2. Associate Professor & Director, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City

3. Professor Emeritus, Graduate Periodontics, School of Dentistry, University of Missouri-Kansas City

Abstract

KEY WORDS: Dental implants, osteopetrosis, bone graft


32 • Vol. 5, No. 6 • June 2013

INTRODUCTIONOsteopetrosis (a.k.a. Albers-Schönberg disease or marble bone disease) was first described in 1904 by Albers-Schönberg.1 Traditionally, two major clinical forms of the disease are noted: The disorder is generally discussed as having two distinct clinical presentations: an autosomal dominant adult (benign) type that is associated with relatively few symptoms2 and the autoso-mal recessive infitile (malignant) type that is typi-cally fatal during infancy or early childhood if untreated.3 Although a diversity of clinical and hereditary types of osteopetrosis shows that defects in several different genes and a vari-ety of biological disturbances cause this dis-order, the pathogenesis involves failure of osteoclastic-mediated resorption of host bone.4,5

Normal bone growth and physiologic turnover is achieved by a balance between cell mediated bone formation (osteoblasts), and cell mediated bone resorption (osteoclasts). Although the exact pathogenic mechanism of osteopetrosis is unknown, a deficiency in the osteoclastic enzyme carbonic anhydrase has been observed.5-7 The absence of carbonic anhydrase results in a defec-tive proton (H+) pump which, in turn, prevents the development of the localized acidic environ-ment required for effective resorption of bone.5-7

Because osteoblastic function is unaf-fected, bone formation continues and eventually becomes excessively dense. Bone thus affected typically exhibits increased radiographic den-sity characterized by a chalky white presentation that, paradoxically, is unable to resist average stressors and thus easily fractures.6,7 The inci-dence of osteopetrosis has been reported at 1 in 20,000 to 500,000 for the dominant form and 1 in 200,000 for the recessive form.6 The disor-

der is generally diagnosed through skeletal x-rays with confirmation by bone density tests and/or bone biopsy.6 Full blown osteopetrosis can lead to anemia and leukopenia due to encroachment of osseous structure upon the marrow spaces.6

Although the clinical severity of the dis-ease varies widely, given the osteoclastic dys-function inherent to osteopetrosis, it may be argued that results of intra-oral osseous graft-ing may be compromised. Even with allograft materials, osteoclastic mediated bone resorp-tion must precede osteoblastic mediated bone apposition. Thus, the pathobiology becomes a potential complication to consider when treat-ing an osteopetrotic patient presenting with peri-implantitis that requires surgical intervention.

Several techniques and modalities have been proposed for regenerating the supporting struc-tures around implants demonstrating peri-implan-titis.7-11 Treatment of peri-implantitis, depending on severity of bony involvement, may involve a simple non-surgical therapy with the adjunctive use of local and/or systemic antibiotics or may require more aggressive therapy such as access flap surgery, implant decontamination via ultra-sonics, air-abrasion or lasers followed by osse-ous grafting.7-11 The purpose of this article is to present a case report showing osseous regen-eration around an implant with peri-implantitis in a patient with a mild form of osteopetrosis.

METHODS Patient PresentationThe patient, a 61 year old Caucasian female pre-sented to the University of Missouri-Kansas City, School of Dentistry, Graduate Periodontics Clinic on February 2, 2009 for evaluation of peri-implant disease involving a dental implant in the #19 posi-

Driver et al


Driver et al

tion. The patient related an extensive medical history including a physician-diagnosed osteope-trosis. The patient had been seen in 1993 by an orthopedic specialist after a motor vehicle acci-dent to rule out an incidental finding of sclerotic vertebrae. Subsequent long bone surveys were performed and demonstrated sclerosis bilater-ally in the proximal femur and skull. The patient denied a family history of bone disease and per-sonal history of fractures. The presence of scle-rotic changes in the vertebrae as well as the metaphysical areas of the long bones was consis-tent with a diagnosis of osteopetrosis tarda. Two separate measurements of serum and urine NTX (N-telopeptide of type 1 collagen) revealed levels at the upper limits of the normal range, suggesting the presence of osteoclastic activity. However, bone density values were significantly elevated with T-scores of 7.7 and 8.8 for the spine and hip, respectively. These findings indicated that bone

density was 7-8 standard deviations above the reference population norm. In October of 2006 the patient was involved in a second motor vehicle accident and suffered a fractured left femur. Open reduction and internal fixation with titanium plates and screws were utilized to stabilize the frac-tured segments. In June of 2007 this hardware had to be removed and replaced due to a non-union of healing. In July of 2007 the new hard-ware was removed along with much of the femur and replaced with a substitute titanium femur.

In December of 2006, the patient had three endosseous implants placed in the areas of #19, #29, and #30. Implant #19 was restored in December of 2007 with a cement retained resto-ration using self-curing resin cement (RelyX 3M ESPE). The initial periodontal evaluation revealed probing depths of 6-8mm around implant #19 with bleeding on probing (Figures 1,2). Occlusal evaluation revealed no heavy centric contacts, lat-

Figure 1: Pre-treatment view of maxillary and mandibular left posterior sextants showing generalized poor oral hygiene. Implant in #19 area exhibits chronic inflammation.

Figure 2: Pre-treatment view of lingual tissues in area of #19 (implant) and #20.

34 • Vol. 5, No. 6 • June 2013

eral, or non-working interferences. Radiographic evaluation revealed bone loss to the third major thread on the distal of implant #19 (Figure 3). Various treatment options were presented to the patient with her consenting to have surgical based guided tissue regeneration (GTR) performed.

TreatmentAnesthesia was obtained by mandibular inferior alveolar and long buccal injections, using 72mg of Lidocaine 2% with 0.036 mg epinephrine. The abutment and cemented restoration on implant #19 were removed as one unit, following which a fetid odor and the presence of highly inflamed and irritated sulcular tissues were noted (Figure 4). In addition, overextended porcelain and excess residual cement were observed on the abutment, extending in some areas to the junction between the abutment and implant platform (Figure 5).

Full thickness buccal and lingual mucoperios-teal flaps were reflected via sulcular incisions with a distal release. Granulation tissue was removed using ultrasonics and manual instrumentation. After degranulation, bone loss to the third major thread was noted on the distal of the implant and extended to the buccal and lingual (Figures 6,7). The exposed implant surface was detoxified using micro air-abrasion followed by application of a tetracycline paste. The tetracycline (TCN) paste was prepared by mixing the contents of a single 250 mg capsule with just enough sterile saline to give it a thick but adaptable consistency when applied with cotton pellets. The TCN paste was allowed to sit for 5 minutes and then was rinsed with copious amounts of sterile saline. A new sterile implant cover screw was placed and torqued to the manufacturer recommended speci-fication. The area distal and buccal of the implant

was decorticated using a small round bur to help stimulate the regional acceleratory phenomenon (Figure 8). Once numerous bleeding points were visualized, the osseous defect was grafted with Puros Allograft® (Zimmer Dental, Carlsbad, CA) and covered with a resorbable cross-linked col-lagen membrane (Figure 9), BioMend Extend® (Zimmer Dental, Carlsbad, CA). Passive primary closure was achieved utilizing a periosteal release and resorbable sutures. Detailed home care instructions were delivered and the patient was appointed for post-operative suture removal at two weeks. The patient was prescribed appropri-

Figure 3: Pre-treatment radiograph showing circumferential vertical-angular intrabony defect with exposure implant threads.

Driver et al


Driver et al

ate analgesics, antibiotics, and 0.12% chlorhexi-dine gluconate (CHX) rinse for the healing period.

At the two-week post-operative appoint-ment, all sutures were in place, no signs of infec-tion were present, and the patient reported

Figure 4: Coronal view of implant and soft tissue wall of the associated gingival pocket showing clinical signs of severe inflammation.

Figure 5: View of prosthesis and reflected mirror image showing over-extended porcelain on to abutment collar and residual dental cement.

Figure 6: Surgical exposure of circumferential bony defect.

Figure 7: Coronal view of circumferential vertical-angular intrabony defect.

36 • Vol. 5, No. 6 • June 2013

minimal discomfort with no post-operative com-plications. All sutures were removed and the surgical site was irrigated with 0.12% CHX. Home care instructions were reinforced and the

patient was appointed for the uncover procedure. A new periapical film was taken (Figure 10)

and the grafted area uncovered after 5 months of healing via a crestal incision that was designed to

Figure 8: View of bony decortication prior to placement of osseous graft material.

Figure 9: Placement of barrier membrane covering osseous graft prior to closure of surgical wound.

Figure 10: Radiograph taken at time of uncovering implant (5 months post-surgery) showing complete bone regeneration.

Figure 11: Clinical confirmation of complete bone regeneration.

Driver et al


Driver et al

Figure 12: Delivery of previous restoration following removal of porcelain overhang and residual dental cement.

Figure 13: Radiograph taken at 3 months following delivery of prosthesis (8 months post-surgery) showing complete bone regeneration.

preserve a band of keratinized tissue on the buc-cal. Excellent osseous integration was observed on the distal, buccal, with new bone formation up to the occlusal aspect of the implant platform on the distal and lingual (Figure 11). The cover screw was removed and the previous restoration was delivered after correcting the deficiencies involv-ing retained cement and over-extended porce-lain (Figure 12). The restoration abutment screw was torqued to the manufactures recommended level, and a peri-apical film was taken to ensure that the abutment was fully seated. A cotton pel-let followed by composite filling material was used to close the occlusal access. The occlusion was verified to ensure that no heavy centric contacts, lateral, or non-working interferences were pres-ent. Resorbable interrupted sutures were used for tissue closure on the mesial and distal of the newly placed restoration. The patient returned 6 weeks later for placement of a buccal free gingival

graft to improve the band of keratinized gingiva.

Post-treatment ResultA post-operative peri-apical film was taken in October 2009 to verify bone levels 3 months after placement of the restoration (Figure 13). Radiographs indicated that bone levels were stable and that 100% osseous regenera-tion was achieved around the failing implant.

DISCUSSIONAlthough an increasingly common procedure, osseous regeneration around failing implants remains a challenging and unpredictable problem. It will continue to become more prevalent and necessary as an increasing number of implants are placed in a wide variety of practice settings. It should be emphasized that proper treatment plan-ning should be performed at all levels of implant therapy to help minimize preventable causes of

38 • Vol. 5, No. 6 • June 2013

implant failures.12 In the current case presenta-tion, 100% osseous regeneration was achieved around a failing implant in a patient with a mild form of osteopetrosis but, never-the-less, with reduced osteoclastic activity. By utilizing pre-dictable and tested GTR techniques13 com-bined with adjunctive detoxification techniques, an excellent result was obtained. Micro air-abrasion as discussed by Dennison14 has demonstrated effectiveness in eliminating bac-terial contaminates from microporosities of the roughened and/or plasma-spray coated implant surface. When exposed to the subgingival envi-ronment, the irregular implant surface topog-raphy promotes colonization by bacteria but is also resistant to manual instrumentation or ultra-sonics.15 Manual and ultrasonic instrumentation cannot access the bacteria and their by-prod-ucts located within surface porosities. On the other hand, the small particles (100 microns) of sodium bicarbonate used in air-abrasion instru-ments are capable of penetrating surface poros-ities and thereby help to eliminate bacteria and their toxic by-products. TCN has long been used as a local and systemic medication to help control periodontopathic bacteria. The manner in which TCN was used in this case report is similar to that presented by Zablotsky et al.16 The TCN paste had enough consistency to stick to the exposed implant surface but still main-tain enough aqueous property to infiltrate the micro-porosities of the roughened implant sur-face. The dual detoxification technique used in this case may have helped promote a more predictable GTR result by eliminating both the presence of bacteria and their endotoxins.

Implant supported restorations may be retained by either retrievable screws or den-

tal cements.17,18 Cemented implant restora-tions have become the restoration of choice due to their relative simplicity.17,19 Advantages of cemented implant restorations include elimi-nation of potential loosening of the prosthesis screw, better esthetics, and control of occlu-sion. If not managed properly, there is a risk of residual excess cement on apical portions of the abutment, the implant itself, or in the surrounding soft tissues. These factors have been associated with peri-implant disease.17,18 Indeed, Wilson17 reported the presence of retained cement on 34 of 42 implants, all exhib-iting peri-implant disease. Excess retained dental cement acts similar to calculus in the sense that it facilitates colonization of bacteria similar to those involved in chronic periodontitis, thereby suggesting that periodontitis and peri-implantitis have a similar pathogenesis.17-22 The inability to effect subgingival oral hygiene due to the excessive dental cement likely facilitates a shift from a microbial complex normally associ-ated with health to a complex of gram-negative bacteria generally associated with disease.17-22

In the present case report, it was known that there was a reduced level of osteoclastic function secondary to the systemic osteope-trosis. It was therefore decided that decortica-tion using a round bur would help stimulate the regional acceleratory phenomena thereby stimu-lating healing and bone formation.23 In theory, the decortication technique creates channels through the cortical plate into the underlying cancellous bone which, in turn, allows migra-tion of osteoprogenitor cells into the grafted bony defect. It should be noted, however, that Greenstein, et al.24 have challenged the bene-fits of decortication with respect to increasing

Driver et al


Driver et al

the success of bone regeneration techniques.Occlusal analysis was also scrutinized for

any heavy centric contacts, lateral interfer-ences, and non-working interferences. Stud-ies by Salvi and Bragger25 and Adell et al.26 have demonstrated the destructive effects of occlusal disharmony on implants. In this sce-nario a short 8.0 x 5.0 mm diameter implant was placed in December of 2006. A short (< 10mm) implant was necessary due to close proximity of the inferior alveolar canal to the alveolar crest. The short implant was then restored with a tall restoration leading to a 1:1 crown:root ratio. A pre-prosthetic vertical ridge augmentation would not have improved the situation due to normal ridge heights. An inferior alveolar nerve repositioning surgery was recommended to facilitate placement of a longer implant but declined by the patient.

CONCLUSIONRegeneration of osseous support around a failing implant in a patient with mild osteope-trosis is possible using the combined tech-nique of degranulation with manual and ultrasonic instrumentation, detoxification with air-abrasion and tetracycline paste, fol-lowed by decortication and grafting with allograft bone augmentation material. ●

Correspondence:

Dr. Charles M. Cobb

424 West 67th Terrace

Kansas City, MO 64113

Phone: 816-444-3167

Fax: 816-444-8673

E-mail: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.References1. Whyte MP. Sclerosing bone disorders. In: Favus

MJ, ed., Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 6th ed., American Society for Bone and Mineral Rsearch, Washington, D.C., 2006, pp. 398.

2. Askmyr M, Flores C, Fasth A. Richter J. Prospects for gene therapy of osteopetrosis. Curr Gene Ther 2009;9(3):150-159.

3. Del Fattore A, Cappariello A, Teti A. Genetics, pathogenesis and complications of osteopetrosis. Bone 2008;42(1):19-29.

4. Whyte MP. Osteopetrosis. In: Royce PM, Steinmann B, eds., Connective Tissue and Its Heritable Disorders, 2nd ed., Wiley-Liss, New York, NY, 2002, p. 789-907.

5. Tolar J, Teitelbaum SL, Orchard PJ. Osteopetrosis. N Engl J Med 2004;351(27):2839-2849.

6. Stark Z., Savarirayan R. Osteopetrosis: Review. Orphanet J Rare Dis 2009;4:5-17.

7. Buchter A, Kleinheinz J, Meyer U, Joos U. Treatment of severe peri-implant bone loss using autogenous bone and a bioabsorbable polymer that delivered doxycycline (Atridox). Br J Oral Maxillofac Surg 2004;42(5):454-456.

8. Deppe H, Horch H-H, Neff A. Conventional versus CO2 laser-assisted treatment of peri- implant defects with the concomitant use of pure-phase $-tricalcium phosphate: A 5-year clinical report. Int J Oral Maxillofac Implants 2007;22(1):79-86.

9. Lang NP, Mombelli A, Tonnetti MS, Bragger U, Hammerle CHF. Clinical trials on therapies for periimplant infections. Ann Periodontol 1997;2:343-356.

10. Lang NP, Berglundh T, Heitz-Mayfield LJ, Pjetursson BE, Salvi GE, Sanz M. Consensus statements and recommended clinical procedures regarding implant survival and complications. Int J Oral Maxillofac Implants 2004;19(Suppl.):150-154.

11. Romanos GE, Nentwig GH. Regenerative therapy of deep peri-implant infrabony defects after CO2 laser implant surface decontamination. Int J Periodont Restor Dent 2008;28(3):245-255.

12. Chuang S.K., Wei L.J., Douglass C.W., Dodson T.B., Risk Factors for Dental Implant Failure: A Strategy for the Analysis of Clustered Failure-time Observations. J Dent Res 2002;81(8):572-577.

13. Mellonig JT, Triplett RG. Guided Tissue Regeneration and Endosseous Dental Implants. Int J Periodont Restor Dent 1993;13(2):108-119

14. Dennison DK, Huerzeler MB, Quinones C, Caffesse RG. Contaminated implant surfaces: an in vitro comparison of implant surface coating and treatment modalities for decontamination. J Periodontol 1994;65(10):942-948.

15. Gatewood RR, Cobb CM, Killoy WJ. Microbial colonization on natural tooth structure compared with smooth and plasma-sprayed dental implant surfaces. Clin Oral Implants Res 1993;4(1):53-64.

16. Zablotsky MH, Diedrich DL, Meffert RM. Detoxification of endotoxin-contaminated titanium and hydroxyapatite-coated surfaces utilizing various chemotherapeutic and mechanical modalities. Implant Dent 1992;1(2):154-158.

17. Wilson TG, Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J

Periodontol 2009;80(9):1388-1392.18. Callan DP, Cobb, C.M. Excess cement and

peri-implantitis. J Implants Adv Clin Dent 2009;1(6):61-68.

19. Mombelli A, van Oosten MAC, Schurch E, Lang NP. The microbiota associated with successful or failing osseointegrated titanium implants. Oral Microbiol Immunol 1987;2(4):145-151.

20. Leonhardt A, Berglundh T, Ericsson I, Dahlen G. Putative periodontal pathogens on titanium implants and teeth in experimental gingivitis and periodontitis in beagle dogs. Clin Oral Implants Res 1992;3(3):112-119.

21. Callan DP, Cobb CM, Williams KB. (2005) DNA probe identification of bacteria colonizing internal surfaces of the implant-abutment interface: A preliminary study. J Periodontol 2005;76(1):115-120.

22. Shibli JA, Melo L, Ferrari DS, Figueiredo LC, Faveri M, Feres M. Composition of supra- and subgingival biofilm of subjects with healthy and diseased implants. Clin Oral Implants Res 2008;19(10):975-982.

23. Garg AK. The regional acceleratory phenomenon: an up-to-date rationale for bone decortication. Dent Implantol Update 1997;8(8):63-64.

24. Greenstein G, Greenstein B, Cavallaro J, Tarnow D. The role of bone decoortications in enhancing the results of guided bone regeneration: A literature review. J Periodontol 2009;80(2):175-189.

25. Salvi GE, Brägger U. Mechanical and technical risks in implant therapy. Int J Oral Maxillofac Implants 2009;24(Suppl):69-85.

26. Adell R., Lekholm U., Rockler B., Branemark P.-I. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981:10(6):387-416.

Wilcko et al

Peri-implantitis is characterized by bone destruction around dental implants due to the host immune-inflamma-

tory response induced by biofilm accumula-tion. Several approaches have been proposed to treat peri-implantitis, including mechanic debridement, antimicrobial therapy, and resec-tive or regenerative surgical therapy. The pres-ent case report describes a peri-implantitis case treated by a surgical open flap debride-ment, decontamination of the implant surface

with povidone-iodine and fill of the adjacent osseous defect with autogenous bone graft. After 20-month follow-up, the pocket depth reduction and radiographic fill of the defect could be observed. Therefore, it can be con-cluded that this therapeutic approach could promote clinical and radiographic improve-ments to the patient. However, more random-ized controlled clinical trials are necessary for further understanding about the best approaches for the treatment of peri-implantitis.

Treatment of Peri-implantitis Using Open Flap Debridement and Iodine Solution with

Autogenous Bone Graft: A Case Report

Miki Taketomi Saito, DDS1 • Mauro Pedrine Santamaria, DDS, MS, PhD2

Karina Gonzales Silvério, DDS, MS, PhD,1 Enilson Antônio Sallum, DDS, MS, PhD, Professor3

1. Assistant Professor, Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, São Paulo, Brazil.

2. Assistant Professor Department of Periodontology, College of Dentistry, State University of São Paulo - UNESP, São José dos Campos, São Paulo, Brazil.

3. Professor, Department of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, São Paulo, Brazil.

Abstract

KEY WORDS: Peri-implantitis, dental implants, guided bone regeneration


42 • Vol. 5, No. 6 • June 2013

IntRODuctIOnPeri-implant diseases are characterized by inflammatory lesions that involve tissues around dental implants, which is a result of biofilm accumulation. They can be classified into peri-implant mucositis or peri-implanti-tis.1 Peri-implant mucositis corresponds to an inflammatory reaction in the implant surround-ing soft tissues, whereas peri-implantitis is the inflammation of the soft tissues and involves the loss of supporting bone around an implant.2,3 Clinically, this inflammation is detected by the presence of bleeding on probing;1 other clini-cal signs (e.g., suppuration, redness, and swell-ing) may be observed.4 Radiographs may be required to evaluate bone loss around implants due to peri-implantitis and differentiate it from the normal bone remodeling.5 In studies about peri-implantitis prevalence, the reported esti-mate is that it occurs in about 28%6,7 to 56%8 of individuals and between 12%7 and 43%8 of the implants. Therefore, the peri-implantitis treatment is a topic of increasing interest. How-ever, only a few studies have provided data on the prevalence of peri-implant diseases; there-fore, these data may be underestimated.3,9

For treating peri-implant mucositis, the non-surgical mechanic therapy is effective in reducing the tissue inflammation; the adjunc-tive use of antimicrobial mouth rinse can improve the results of this therapy.10 With respect to peri-implantitis, the non-surgical mechanic therapy has not demonstrated to be equally effective.10 Therefore, surgical therapies have been proposed for treating peri-implan-titis, including open flap debridement as well as resective or regenerative approaches.3,11

Although some studies are aimed at

establishing protocols treatment for peri-implantitis, there is no consensus about the best way to perform the implant surface debridement, decontamination, and regen-eration of the bone defect.12 In this con-text, the aim of the present paper is to report a case of peri-implantitis treated with a sur-gical approach of open flap debridement for implant surface decontamination with iodine solution associated with a regenera-tive approach using autogenous bone graft.

cASE REPORtA 43-year-old white male, presenting a good general medical condition was referred to the Graduate Clinic of the Piracicaba Dental School reporting bad breath as chief complaint. He also reported he had difficulty maintaining hygiene on a dental implant placed 2 years before, as well as bleeding in this area. Clinical examina-tion revealed a dental implant (replacing the inferior left first molar) that has never received crown reconstruction; the implant presented a probing depth (PD) of 5 mm and bleeding on probing (BoP). Additionally, there was a bridle that made proper implant cleaning very demand-ing (Figure 1). Radiographs showed a crater-like peri-implant bone defect (3 mm) involving three implant screws (Figure 2). Thus, the diag-nosis of peri-implantitis was established. The patient was informed about his problem and all the treatment options for the case; thereaf-ter, he consented for the treatment as follows.

The initial treatment consisted of oral hygiene instructions, mechanical treatment with intrasulcular brushing and subgingival 10% povidone-iodine Riodeine® (Rioquímica™, São José do Rio Preto, SP, Brazil) irrigation,

Saito et al


which was performed during 5 to 7 minutes in a single session. Despite the improvement of the general oral hygiene observed afterwards, the dental implant still showed inflammation

signs after 1-month of follow-up. Then, a sur-gical approach was proposed for implant sur-face decontamination and filling of peri-implant defect with autogenous bone graft. Under local

Figure 1: Initial clinical aspect of the dental implant that was diagnosed with peri-implantitis.

Figure 2: Initial radiographic aspect of the dental implant that was diagnosed with peri-implantitis.

Figure 3: Peri-implant defect visualization after mucoperiosteal flap elevation. Note the presence of extensive granulation tissue.

Figure 4: Peri-implant defect visualization after granulation tissue removal.

Saito et al

44 • Vol. 5, No. 6 • June 2013

anesthesia Alphacaine® (DFL™, Rio de Janeiro, RJ, Brazil), two incisions were made mesi-ally and distally to the dental implant; a muco-periosteal flap was raised to allow implant and bone defect visualization (Figure 3). After com-plete granulation tissue removal, the implant surface and bone defect could be observed (Figure 4). The implant surface decontamina-tion was performed using gauze soaked with 10% povidone-iodine. Afterward, autogenous bone graft was obtained from an adjacent area and placed into the peri-implant defect to cover all implant screws (Figure 5). The flap was then repositioned and sutured (Nylon 5.0, Ethicon™, São José dos Campos, SP, Brasil). After this surgical procedure, the patient was instructed to take analgesics (500 mg sodium dipyrone every 6 h for 2 d) and to discontinue toothbrushing around the surgical site for 15 days after surgery. During this period, plaque

control was achieved with a 0.12% chlorhexi-dine rinse twice a day. After this period, gentle toothbrushing with a soft-bristle toothbrush was allowed. Sutures were removed after 7 days; the patient was enrolled in a periodontal main-tenance program (i.e., professional plaque con-trol and oral hygiene instruction) weekly during the first month, then monthly during the con-secutive months. After 20-mouth follow-up, a reduction of probing depth to 3 mm and radio-graphic bone fill could be observed (Figure 6).

DIScuSSIOnBecause of the similarities between the inflam-matory diseases induced by biofilm accumula-tion on teeth and implants, some approaches that have been proposed to treat peri-implant diseases were initially based on previous evi-dences for treatments of periodontal dis-eases.10 In this context, the primary goal of

Figure 5: Peri-implant defect filled with autogenous bone graft obtained from adjacent area.

Figure 6: Radiographic aspect in 20-month follow-up after regenerative surgical approach suggesting defect bone filling.

Saito et al


peri-implant disease treatment is the reduc-tion of microbial challenge and control of the inflammatory reaction to re-establish a healthy peri-implant tissue.13 The therapeu-tic modalities for peri-implantitis comprise a non-surgical approach and surgical approach. The non-surgical approach includes mechani-cal debridement alone or combined with anti-septic agents or laser devices. The surgical approach includes open flap surgery that may be associated with resective or regenerative techniques. Although the non-surgical ther-apy could be effective for treating peri-implant mucositis, it does not seem to be as effective for peri-implantitis as it is for teeth.10 In peri-implantitis, the surgical approach has shown to perform better than non-surgical techniques.11,14

The surgical approach allows better access to defects and provides a better access for implant surface decontamination. In this con-text, the literature reports that only mechanical debridement on roughened implant surfaces contaminated with bacteria may have limited effect; the adjunctive use of chemical agents is recommended to improve treatment out-comes.12,15 However, there is no evidence in the literature to demonstrate a superior decontamination method.11 In order to decon-taminate the implant surface, a wide range of methods have been proposed in the litera-ture, such as mechanical debridement, the use of antiseptics/antibiotics and laser ther-apy.3,11 In an experimental study, the influence of the non-surgical approach associated with non-submerged healing and the surgi-cal approach associated with various implant surface decontamination methods (laser ther-apy; ultrasonic debridement; plastic curettes

associated with local application of metroni-dazole gel) and submerged healing was evalu-ated in peri-implantitis lesions in dogs.14 The authors observed that all treatments resulted in improvement of clinical parameters; however, the surgical approach associated with implant surface decontamination and submerged healing leads to better radiographic improve-ment. Moreover, when the specimens were evaluated histologically, surgical approaches also demonstrated better bone–implant con-tact compared to non-surgical approach.

In the present case, the surgical approach was performed and associated with decon-tamination of the implant surface using gauze soaked with 10% povidone-iodine solution. Povidone-iodine solution is considered an inex-pensive and nonhazardous broad-spectrum antiseptic that has been used as an adjunct in periodontal therapy; it has demonstrated by a systematic review that it may improve PD reduc-tion during scaling and root planing.16 The application of povidine-iodine with gauze was chosen to avoid damage to implant surface by metal curettes and ultrasonic tips or risk of sur-gical emphysema by air powder abrasives.11,13

Additionally, the correction of peri-implant defect should be one of the treatment objec-tives to allow efficient biofilm control by the patient and to eliminate micro-environments favorable for a pathogenic microbiota.3 The correction of these defects can be obtained by resective or regenerative techniques; how-ever, the latter are preferable because the ulti-mate goal of peri-implantitis treatment is to regenerate lost tissue11,17,18 and re-establish the osseointegration along the previously con-taminated implant surface.11,17 Autogenous

Saito et al

46 • Vol. 5, No. 6 • June 2013

bone, xenografts, alloplastic materials and membranes have been used in regenerative techniques, which demonstrate variable lev-els of bone fill and re-osseointegration.11,17,18

In an animal model study, the regenerative treatments for bone defects around implants were evaluated. The defects were randomly assigned to receive the following: a bioabsorb-able membrane; a mineralized bone xenograft; or a combination of both. The results showed non-significant difference regarding the range of bone fill among all the three treatments.19 In a clinical study, the treatment of peri-implan-titis defects using autogenous bone grafts was evaluated in 25 implants diagnosed with peri-implantitis from 17 patients.18 During the observation period of up to 3 years, the use of autogenous bone graft demonstrated to be an efficacious treatment approach for restoring hard tissue lost by peri-implantitis. In another clinical study, three different techniques of bone regeneration in peri-implantitis lesions were compared: autogenous bone graft alone or associated with resorbable or non-resorbable barrier.20 At the 3-year follow-up evaluation, it was observed that all treatments revealed signif-icant improvement of peri-implant probing depth from baseline; however, differences in surgical approach did not affect the treatment outcome. Therefore, this study concluded that the addi-tional application of barrier does not improve the overall treatment outcome. This is in accor-dance with a case-control study comparing the use of a bone substitute alone or associated with a resorbable membrane with a follow-up over 3 years where no significant difference in defect bone fill was observed.21 The current lit-erature demonstrates no additional beneficial

effect on the use of membranes associated with grafts,11,19-21 membrane exposure as a frequent complication,11,20,22 and the use of autogenous bone graft is effective for treating peri-implant bone defects.18 Therefore, it was decided to use autogenous bone graft alone in the pres-ent case to avoid complications related to membrane exposure during the healing period.

Regarding the amount of defect bone fill, the chosen material as well as the peri-implant defect configuration are important and play a key role in treatment.11,23 A clinical study investigating the impact of defect con-figuration on the clinical outcome of surgical regenerative therapy using a xenograft in com-bination with a collagen membrane in peri-implantitis lesions demonstrated that intra-bony/circumferential defects tend to obtain higher improvements in probing depth reduction and clinical attachment level when compared with circumferential defects or semi-circumferential associated with buccal dehiscence at 6 and 12 month follow-up.23 In the present report, the peri-implant defect presented a favorable ana-tomical configuration. Despite a buccal bony dehiscence, the mesial, distal and lingual bone crest still remained in the level of the top of the implant, which could allow the autogenous graft placement and reposition of the mucoperi-osteal flap in an adequate position. The radio-graphic examination after 20 month follow-up reveals the defect filling (Figure 6). However, the radiographic image cannot elucidate the type of healing or if re-osseointegration has occurred in fact. Nevertheless, this result does not discredit the clinical benefits obtained in this case by the regenerative approach, such as probing depth reduction and peri-implant

Saito et al


defect filling, which can promote better con-ditions for adequate hygiene and a less favor-able environment for anaerobic pathogens.

cOncluSIOn The therapeutic approach for treatment of peri-implantitis using open flap debridement and iodine solution associated with autogenous bone graft was able to promote clinical and radiographic benefits in the case reported. How-ever, it is not established in the literature which is the most effective approach for the treat-ment of peri-implantitis. Therefore, randomized controlled clinical trials with long-term follow-up are necessary to elucidate this question. ●

correspondence:Miki Taketomi SaitoDept. of Prosthodontics and Periodontics, Division of Periodontics, Piracicaba Dental School, University of Campinas - UNICAMP, São Paulo, Brazil.Av. Limeira, n°. 901. Piracicaba. São Paulo. Brazil. P.O. Box 52.e-mail: [email protected]/ Fax: +55 19 2106-5301

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases.

J Clin Periodontol. Sep 2008;35(8 Suppl):286-291.2. Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth

European Workshop on Periodontology. J Clin Periodontol. Sep 2008;35(8 Suppl):282-285.

3. Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of interventions to treat peri-implantitis: a Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implantol. Summer 2008;1(2):111-125.

4. Heitz-Mayfield LJ. Peri-implant diseases: diagnosis and risk indicators. J Clin Periodontol. Sep 2008;35(8 Suppl):292-304.

5. Adell R, Lekholm U, Rockler B, Branemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. Dec 1981;10(6):387-416.

6. Fransson C, Wennstrom J, Berglundh T. Clinical characteristics at implants with a history of progressive bone loss. Clin Oral Implants Res. Feb 2008;19(2):142-147.

7. Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence of subjects with progressive bone loss at implants. Clin Oral Implants Res. Aug 2005;16(4):440-446.

8. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol. Apr 2006;33(4):290-295.

9. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. J Clin Periodontol. 2002;29 Suppl 3:197-212; discussion 232-193.

10. Renvert S, Roos-Jansaker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review. J Clin Periodontol. Sep 2008;35(8 Suppl):305-315.

11. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. J Clin Periodontol. Sep 2008;35(8 Suppl):316-332.

12. Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri-implantitis: a systematic review. J Clin Periodontol. Jul 2008;35(7):621-629.

13. Schou S, Berglundh T, Lang NP. Surgical treatment of peri-implantitis. Int J Oral Maxillofac Implants. 2004;19 Suppl:140-149.

14. Schwarz F, Jepsen S, Herten M, Sager M, Rothamel D, Becker J. Influence of different treatment approaches on non-submerged and submerged healing of ligature induced peri-implantitis lesions: an experimental study in dogs. J Clin Periodontol. Aug 2006;33(8):584-595.

15. Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol 2000. 2002;28:177-189.

16. Sahrmann P, Puhan MA, Attin T, Schmidlin PR. Systematic review on the effect of rinsing with povidone-iodine during nonsurgical periodontal therapy. J Periodontal Res. Apr 2010;45(2):153-164.

17. Renvert S, Polyzois I, Maguire R. Re-osseointegration on previously contaminated surfaces: a systematic review. Clin Oral Implants Res. Sep 2009;20 Suppl 4:216-227.

18. Behneke A, Behneke N, d’Hoedt B. Treatment of peri-implantitis defects with autogenous bone grafts: six-month to 3-year results of a prospective study in 17 patients. Int J Oral Maxillofac Implants. Jan-Feb 2000;15(1):125-138.

19. Nociti Junior FH, Caffesse RG, Sallum EA, Machado MA, Stefani CM, Sallum AW. Clinical study of guided bone regeneration and/or bone grafts in the treatment of ligature-induced peri-implantitis defects in dogs. Braz Dent J. 2001;12(2):127-131.

20. Khoury F, Buchmann R. Surgical therapy of peri-implant disease: a 3-year follow-up study of cases treated with 3 different techniques of bone regeneration. J Periodontol. Nov 2001;72(11):1498-1508.

21. Roos-Jansaker AM, Lindahl C, Persson GR, Renvert S. Long-term stability of surgical bone regenerative procedures of peri-implantitis lesions in a prospective case-control study over 3 years. J Clin Periodontol. Jun 2011;38(6):590-597.

22. Esposito M, Hirsch J, Lekholm U, Thomsen P. Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature. Int J Oral Maxillofac Implants. Jul-Aug 1999;14(4):473-490.

23. Schwarz F, Sahm N, Schwarz K, Becker J. Impact of defect configuration on the clinical outcome following surgical regenerative therapy of peri-implantitis. J Clin Periodontol. Mar 30 2010.

Saito et al

ATTENTION PROSPECTIVE

AUTHORSJIACD wants to publish

your article!


For complete details regarding publication in JIAcD,

please refer to our author guidelines at the following link:

http://www.jiacd.com/authorinfo/ author-guidelines.pdf

or email us at: [email protected]

peri-implantitis issue - jiacd41 treatment of peri-implantitis using open flap debridement and...

Documents