Treatment of Peri-Implantitis with a Diode Laser
A long-term case follow-up
Gregori M. Kurtzman, DDS, MAGD | Markus Weitz, DDS | Ron Kaminer, DDS | Daniel D. Gober, DDS
The prevalence of implant complications is rising significantly as more patients are treated with implants. As with periodontitis associated with natural teeth, periodontal disease can affect implants. This can range from gingival inflammation and the absence of bone loss, to significant bone loss and mobility of the fixture when the disease process is not identified early or a “watch and wait” attitude is taken. Peri-implantitis is a frequent enough occurrence after implant placement that treatment needs to be accomplished to prevent loss of the implant.
Treatment has traditionally involved flapping the site and mechanical debridement with surgical hand instruments to remove any granulation tissue present on the implant’s threads due to the limitations of the surgical tools that might require removal of additional bone to reach areas that are not visible. Success relates to debriding and sterilizing all exposed threads, with success diminishing as more surface area is left untreated. Diode lasers have several benefits related to peri-implantitis treatment. These include easier access to limited access areas due to the small diameter of the flexible glass fiber without the need to remove as much bone as may be required when only surgical instruments are used, and the ability to sterilize the implant’s contaminated surface, eliminating any bacteria that caused the disease and preventing their hampering of healing after treatment. Another added benefit of a diode in these procedures is biostimulation of the mesenchymal stem cells in the surrounding bone and soft tissue, an important tool for regenerative therapy and tissue engineering for better healing.1 Thus, the diode laser is a good adjunct in the treatment of peri-implantitis, improving the clinical results observed with more traditional methods.2
A 64-year-old man presented with a fistula draining on the buccal of the upper right canine. The fistula was located distal to the canine midline in close proximity to the gingival margin (Figure 1). A gutta-percha cone was inserted into the fistula to trace the origination point of the draining infection and a radiograph was taken. Radiographically, it was determined that the fistula traced to the apical of the implant situated at tooth No. 6. Implants had been placed and restored for teeth Nos. 3 through 7 several years prior. The implant was identified as a Branemark Mark III RP (NobelBiocare, www.nobelbiocare.com) at teeth Nos. 4 through 6 and a NobelReplace (NobelBiocare) at tooth No. 7. A radiograph was taken to evaluate the underlying osseous structure around the implant, which demonstrated a radiolucency associated with the apical of implant No. 6 and crestal bone loss with thread exposure under the soft tissue on implant No. 7. Clinically, no recession was noted and no implant mobility was detected.
The patient was informed of the clinical issue and treatment options, including removal of the ailing implant and grafting the site, and following integration of the graft and an appropriate healing period, a new implant could be placed and restored. The other option was to flap the area, clean out any granulation tissue, and treat the site with a diode laser and graft to replace any lost bone. The patient was made aware that the latter option required site evaluation once entered and should the implant have mobility after debridement, the implant area would need to be explanted. The patient chose peri-implantitis repair.
A single dose of prophylactic antibiotic (2 g amoxicillin) was given orally 1 hour preoperatively. A local anesthetic, Articaine (Septocaine® 1:100,000 epinephrine, Septodont, www.septodontusa.com) was administered for local infiltration on the buccal and palatal of the treatment area. A horizontal incision was made from the distal of the first premolar to the mesial of the lateral incisor several millimeters apical to the gingival margin to limit posttreatment recession potential. A vertical releasing incision was made at the mesial and distal extent of the horizontal incision and a full-thickness flap was elevated. Upon flap reflection it was noted that a large dehiscence was present on tooth No. 6 from the crest to several millimeters beyond the apical of this implant. Additionally, some dehiscence was noted on the buccal of implant No. 5 with threads minimally covered with bone over the apical half of the implant, and implant No. 7 presented with 30% to 50% of the threads circumferentially denuded of bone with complete soft-tissue coverage. A hand instrument was used to remove any gross granulation tissue adherent to the bone and exposed implant threads (Figure 3). An activated 300-µm diode tip on the Picasso laser (AMD LASERS, www.amdlasers.com) set at 1.5 W in continuous mode was used to remove any residual granulation tissue on the exposed threads at the defect and sterilize the defect area.3,4 The diode’s fiber tip was placed into physical contact with the implant surface to remove any residual granulation tissue and sterilize the area of any bacteria that contributed to the peri-implantitis, leaving clean threads.
After debridement and sterilization, bleeding points in the osseous walls were created. Bio-Oss® (Geistlich Pharma North America Inc., www.geistlich-na.com), a bovine biocompatible porous bone mineral substitute, was packed into the defect around the implant and allowed to absorb blood from the surrounding tissue to form a coagulated mass. The bone graft was built out buccally to create a new buccal plate covering the entire implant below the crestal level (Figure 4). A piece of resorbable membrane (Ossix Plus®, OraPharma, Inc., www.orapharma.com) was trimmed to overlay the osseous graft and end on native bone, and was placed over the graft under the flap. The flap was repositioned and secured with nine interrupted sutures using 5-0 silk to achieve primary closure. A radiograph was taken to document the bone fill of the osseous graft (Figure 5). Hemostasis was confirmed and the patient dismissed. A prescription for Zithromax was given with the instructions to use as the directed until finished. Additionally, a prescription was given for Dolobid 500 mg for pain to be taken BID for the initial 3 days post-surgically. The patient returned after 1 week for suture removal and indicated no significant postoperative discomfort. The site appeared to be healing normally and he was scheduled for a follow-up. At the next postoperative visit, the site appeared to be healed with a lack of inflammation and the patient was placed on a periodontal recall alternative with his general dentist.