Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-201

CASE REPORT Management of an Ailing Anterior Implant Using a Minimally Invasive Flapless Surgical Technique: A Case Report Christos Constantinides,* Jaime Chang, † and Paul Fletcher ‡ x Introduction: Peri-implantitis is an inflammation of the soft and hard tissues surrounding an implant that results in the destruction of alveolar bone. Surgical flaps are usually elevated to allow for thorough debridement and disinfection of the implant surface. This frequently results in gingival recession, crown margin exposure, and a poor esthetic result. This is not desirable in the esthetic zone. In this case report, a minimally invasive flapless technique incorporating the use of curet-tage and antiseptics is used to successfully disinfect a contaminated dental implant to allow for soft tissue readherence and pocket reduction. Radiographic bone fill is also seen. The results have been maintained for 2 years. Case Presentation: A 54-year-old female patient presented with peri-implantitis, characterized by episodic pain and suppuration from a buccal fistula on an implant replacing tooth #10. The implant was placed and provisionally restored 10 years previously. It showed radiographic bone loss to the fifth thread, but it was non-mobile. Treatment consisted of removal of the temporary crown and abutment, which provided access for the surgical curettage of the granulomatous tissue and for the me-chanical debridement of the implant surface with a titanium curet. Chemical detoxification of the implant surface, as well as the abutment, screw, and screw hole, was achieved with the use of sterile saline and a 0.25% sodium hypochlorite solution. Antibi-otics were also prescribed. At a 2-year follow-up, probing depths were reduced to < 4 mm, and there was radiographic bone fill. Conclusions: A minimally invasive flapless technique incorporating surgical curettage debridement of the inflamed soft tis-sue and chemical detoxification with antiseptics can be a viable alternative for the treatment of anterior implants with peri-implantitis, especially when the patient has a high smile line. Successful and effective debridement and disinfection of a previously contaminated implant surface can be achieved without reflecting a flap. Clin Adv Periodontics 2017;7:201-206. Key Words : Bone resorption; decontamination; dental implants; esthetics, dental; inflammation; peri-implantitis. * Private practice, Nicosia, Cyprus. † ‡ Background Peri-implantitis is an inflammation of the peri-implant soft tissues in conjunction with radiographic bone loss beyond what is considered acceptable due to osseous remodeling after the placement of a final restoration. 1 Bleeding on probing (BOP), suppuration, and probing depths (PDs) > 5 mm are clinical signs of peri-implant disease. 2 The aims of treatment are to eliminate inflammation, ar-rest disease progression, and if possible, regenerate the lost Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017 Private practice, Singapore, Republic of Singapore. Division of Periodontics, Columbia University College of Dental Medicine, New York, NY. Private practice, New York, NY. x Submitted January 24, 2017; accepted for publication June 19, 2017 doi: 10.1902/cap.2017.170004 201

Management Of An Ailing Anterior Implant Using A Minimally Invasive Flapless Surgical Technique: A Case Report

Christos Constantinides, Jaime Chang, and Paul Fletcher

Introduction: Peri-implantitis is an inflammation of the soft and hard tissues surrounding an implant that results in the destruction of alveolar bone. Surgical flaps are usually elevated to allow for thorough debridement and disinfection of the implant surface. This frequently results in gingival recession, crown margin exposure, and a poor esthetic result. This is not desirable in the esthetic zone. In this case report, a minimally invasive flapless technique incorporating the use of curettage and antiseptics is used to successfully disinfect a contaminated dental implant to allow for soft tissue readherence and pocket reduction. Radiographic bone fill is also seen. The results have been maintained for 2 years.

Case Presentation: A 54-year-old female patient presented with peri-implantitis, characterized by episodic pain and suppuration from a buccal fistula on an implant replacing tooth #10. The implant was placed and provisionally restored 10 years previously. It showed radiographic bone loss to the fifth thread, but it was non-mobile. Treatment consisted of removal of the temporary crown and abutment, which provided access for the surgical curettage of the granulomatous tissue and for the mechanical debridement of the implant surface with a titanium curet. Chemical detoxification of the implant surface, as well as the abutment, screw, and screw hole, was achieved with the use of sterile saline and a 0.25% sodium hypochlorite solution. Antibiotics were also prescribed. At a 2-year follow-up, probing depths were reduced to <4 mm, and there was radiographic bone fill.

Conclusions: Aminimally invasive flapless technique incorporating surgical curettage debridement of the inflamed soft tissue and chemical detoxificationwith antiseptics can be a viable alternative for the treatment of anterior implantswith peri-implantitis, especiallywhen the patient has a high smile line.Successful and effective debridement anddisinfection of a previously contaminated implant surface can be achieved without reflecting a flap. Clin Adv Periodontics 2017;7:201-206.

Key Words: Bone resorption; decontamination; dental implants; esthetics, dental; inflammation; peri-implantitis.

Background

Peri-implantitis is an inflammation of the peri-implant soft tissues in conjunction with radiographic bone loss beyond what is considered acceptable due to osseous remodeling after the placement of a final restoration.1 Bleeding on probing (BOP), suppuration, and probing depths (PDs) >5 mm are clinical signs of peri-implant disease.2

The aims of treatment are to eliminate inflammation, arrest disease progression, and if possible, regenerate the lost tissues.3 Thorough debridement of the diseased tissue around the implant along with decontamination of the implant surface has been shown to be vital for treatment success. 4 Currently, most of the research is focused on surgical approaches, where a flap is reflected to gain direct access to the implant surface and the peri-implant defect.5 However, this flap reflection can have undesirable esthetic consequences, especially when treating an anterior implant. They include gingival recession, exposure of the crown margin and abutment, and loss of the interdental papillae.6

In this case report, a minimally invasive flapless access procedure, using surgical curettage in combination with mechanical debridement and chemical detoxification, is used to treat an anterior implant with peri-implantitis. Flap reflection was avoided to prevent the esthetic consequences mentioned above. Resolution of the inflammation, reduction of PDs, readherence of the soft tissues to the implant, and radiographic evidence of bone deposition were achieved. The case was followed for 2 years.

Clinical Presentation

A 54-year-old Hispanic female presented to the Department of Periodontology, Columbia University, New York, New York, in April 2013 for chronic pain and suppuration from an implant in site #10. A moderately rough surface external hex implant,‖ which had been placed 10 years previously and never been permanently restored, was provisionalized with an acrylic crown.

Clinically, the implant site presented with erythematous gingiva, a buccal fistula, purulence, and 6- to 7-mm circumferential pocketing (Fig. 1). Radiographic bone loss was visible to the fifth thread (Fig. 2). Due to esthetic concerns, the lesion was treated using a minimally invasive non-flap surgical approach.

Case Management

The patient’s medical history was reviewed, and her written informed consent was obtained for treatment. The area was anesthetized, and the temporary crown and abutment were removed (Fig. 3a) to gain access to contaminated threads through the pocket, without reflecting a flap. On removal of the abutment, the ulcerated soft tissue pocket lining was visualized (Fig. 3b). There was no evidence of residual cement or a loose screw. The chronically inflamed granulomatous gingival pocket lining had a gelatinous consistency and was easily removed by curettage with a titanium curet. This procedure exposed the bacterially contaminated implant platform, screw access opening, and threads, thus providing access for the thorough decontamination of the implant surface with a titanium curet (Fig. 4a). The implant threads and collar were carefully burnished sequentially with cotton pellets soaked in sterile saline7 and a 0.25% sodium hypochlorite solution8 in an attempt to further disrupt the bacterial biofilmand detoxify the implant surface. The peri-implant pocket was then irrigated with sterile saline using a syringe{ to further reduce the microbial concentration (Fig. 4b).7 Subsequently, the underside of the restoration, the abutment, and the contaminated screw were mechanically debrided and disinfected with cotton pellets soaked in the solutions mentioned above (Figs. 4c and 4d).9 The abutment was screwed back in place, and the temporary crown was recemented over it (Fig. 5a).# Excess cement was removed, and pressure was applied on the gingival margin for 1 minute to optimize chances for epithelial and connective tissue readherence. Amoxicillin (250 mg) and metronidazole (250 mg) were prescribed three times daily for 8 days.10 The patient was advised not to brush the surgical site for 2 weeks but to use a 0.12% chlorhexidine mouthwash** twice daily. At the 2-week follow-up, the patientwas asked to resume oral hygiene procedures with a soft-bristle toothbrush and interproximal brushes along with a triclosan toothpaste.††11

Clinical Outcomes

At the 4-week follow-up, the fistula appeared to have resolved, no suppuration was evident, and the mesial papilla had contracted (Fig. 5b). At the 6-month postoperative appointment, there was no evidence of BOP, the sulcus was inflammation free, and PDs were <3 mm (Fig. 6).

A permanent porcelain-fused-to-metal crown was subsequently cemented.‡‡ The patient was placed on a 3-month maintenance regimen. At the 2-year follow-up, PDs were still 2 to 3 mm(Fig. 7), the mesial papilla had mostly re-formed, and there was radiographic evidence of bone fill (Fig. 8).

Discussion

Most studies report that an open-flap surgical approach is indicated for the treatment of peri-implantitis.5 However, creating a gingival flap to the crest of bone would have severed the supracrestal perpendicular connective tissue attachment fibers that were still inserted into the cementum of the adjacent teeth. Removing these fibers would have increased the possibility of flap contraction and subsequent soft tissue recession on healing.

In this esthetically demanding case, the implant with peri-implantitis was treated using a minimally invasive flapless surgical technique.

Removing the chronically inflamed granulomatous tissue provided access to the contaminated threads. Decontamination was performed using cotton pellets soaked in sterile saline7 and a 0.25% sodium hypochlorite solution,8 taking care to compact the pellets to ensure no strands of cotton were inadvertently left behind. The two solutions have been used in previous studies and have been shown to be successful in reducing the bacterial load.4,7,8

As shown in Figure 1, the fistula was approximately at the level of the implant–abutment interface. As bacterial microleakage has been shown at this interface,9 in addition to decontaminating the implant threads, it is also important to decontaminate the underside of the restoration, the screw, the screw opening, and the abutment. It would seem that decontamination of these components contributed to the closure of the fistula in this case.

Based on research,12 due to the expected defect configuration, creating a flap in this area in an attempt to regenerate bone would have been unpredictable and could have led to undesirable esthetic results.12 In this case, even without grafting there is radiographic evidence of bone regrowth at 2 years (Fig. 8). Thorough removal of the biofilm would seem to have made a strong contribution to this occurrence. Although initially there was a slight collapse of the papilla (Fig. 5b), as described in the literature,13 it appeared to re-form over a 2-year period (Fig. 7).

At 2 years, PDs were still 2 to 3mm(Fig. 7). There was no BOP and there was evidence of radiographic bone fill. Shallow PDs and an absence of BOP and progressive bone loss are good indicators of future stability.14,15

In this case, it has been shown that with a minimally invasive non-flap surgical approach, access to the exposed implant threads is possible. This allows for mechanical debridement and chemical detoxification, while optimizing the potential of maintaining the esthetics of implant restoration. Additionally, the thorough decontamination and cleaning of all components of the restoration allowed for readherence of the epithelium and connective tissue to the implant and abutment surfaces. With superior patient home care and regularly scheduled in-office maintenance visits, this result remained stable during the 2-year follow-up period.

Summary

Why is this case new information?

■ It describes a minimally invasive surgical technique to treat anterior implants and minimize the undesirable esthetic consequences of flap surgery.

What are the keys to successful management of this case?

■ The ability to remove the crown and abutment is needed.

■ The peri-implant pocket should allow access to the threads.

■ Thoroughly decontaminate the threads with mechanical and chemical means.

■ Detoxification of implant surface as well as abutment, screw, and screw hole should be performed.

What are the primary limitations to success in this case?

■ The aim is to reduce inflammation and stabilize peri-implant tissues; hence, regeneration is not routinely expected.

■ A strict maintenance regimen is crucial.

■ If “permanent” cement is used, it is difficult to remove the crown and abutment.

Acknowledgment

The authors report no conflicts of interest related to this case report.

CORRESPONDENCE:

Dr. Christos Constantinides, Nicosia Periodontics, 22 Stasicratous St.,
201, Nicosia 1065, Cyprus. E-mail: dr.c@nicosiaperiodontics.com.

References

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

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

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

4.Subramani K, Wismeijer D. Decontamination of titanium implant surface and re-osseointegration to treat peri-implantitis: A literature review. Int J Oral Maxillofac Implants 2012;27:1043-1054.

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

6.Kaldahl WB, Kalkwarf KL, Patil KD, Dyer JK, Bates RE Jr. Evaluation of four modalities of periodontal therapy. Mean probing depth, probing attachment level and recession changes. J Periodontol 1988;59:783- 793.

7.Schwarz F, John G, Mainusch S, Sahm N, Becker J. Combined surgical therapy of peri-implantitis evaluating two methods of surface debridement and decontamination. A two-year clinical follow up report. J Clin Periodontol 2012;39:789-797.

8.Gosau M, Hahnel S, Schwarz F, Gerlach T, Reichert TE, Bu¨ rgers R. Effect of six different peri-implantitis disinfection methods on in vivo human oral biofilm. Clin Oral Implants Res 2010;21:866-872.

9.Teixeira W, Ribeiro RF, Sato S, Pedrazzi V. Microleakage into and from two-stage implants: An in vitro comparative study. Int J Oral Maxillofac Implants 2011;26:56-62.

10.Slots J; Research, Science and Therapy Committee. Systemic antibiotics in periodontics. J Periodontol 2004;75:1553-1565.

11.Sreenivasan PK, Vered Y, Zini A, et al. A 6-month study of the effects of 0.3% triclosan/copolymer dentifrice on dental implants. J Clin Periodontol 2011;38:33-42.

12.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 2010;37:449-455.

13.Jemt T, Lekholm U. Single implants and buccal bone grafts in the anterior maxilla: Measurements of buccal crestal contours in a 6-year prospective clinical study. Clin Implant Dent Relat Res 2005;7:127-135.

14.Lang NP, Adler R, Joss A, Nyman S. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol 1990;17:714-721.

15.Mombelli A, Lang NP. The diagnosis and treatment of peri-implantitis. Periodontol 2000 1998;17:63-76.

indicates key references.


Private practice, Nicosia, Cyprus.

† Private practice, Singapore, Republic of Singapore.

‡ Division of Periodontics, Columbia University College of Dental Medicine, New York, NY.

x Private practice, New York, NY.

Submitted January 24, 2017; accepted for publication June 19, 2017

doi: 10.1902/cap.2017.170004

Read the full article at http://onlinedigeditions.com/article/Management+Of+An+Ailing+Anterior+Implant+Using+A+Minimally+Invasive+Flapless+Surgical+Technique%3A+A+Case+Report/2908927/445120/article.html.

Previous Page  Next Page


Publication List
Using a screen reader? Click Here