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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 49-53

Treatment of peri-implantitis with implantoplasty and diode laser


Department of Periodontology and Implantology, Faculty of Dental Sciences, DDU, Nadiad, Gujarat, India

Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Anal Rutvik Trivedi
3, Lakshya La Villa, Opp. Lambhavel Hanumanji Temple, Anand-Lambhavel Road, Anand - 388 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohr.ijohr_29_19

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  Abstract 


Dental implant surgery has developed to a widely used procedure for dental rehabilitation and is a secure and predictable procedure. But, some local and systemic risk factors can result in higher failure rates and affect implant survival. Peri-implant disease, namely peri-implantitis, have been extensively studied in present era as a major cause of implant failure. There are various treatment modalities to treat peri-implantitis, which give satisfactory results and improve survival rate of implant. Though it is difficult to determine what approach will improve implant survival, present case report is an attempt to treat peri-implantitis with implantoplasty and diode laser followed by regenerative periodontal therapy.

Keywords: Diode laser, implantoplasty, peri-implantitis, regenerative periodontal therapy


How to cite this article:
Trivedi AR, Patel VG, Gupta SS, Jathal BS. Treatment of peri-implantitis with implantoplasty and diode laser. Indian J Oral Health Res 2019;5:49-53

How to cite this URL:
Trivedi AR, Patel VG, Gupta SS, Jathal BS. Treatment of peri-implantitis with implantoplasty and diode laser. Indian J Oral Health Res [serial online] 2019 [cited 2019 Dec 10];5:49-53. Available from: http://www.ijohr.org/text.asp?2019/5/2/49/271145




  Introduction Top


Nevertheless, despite the high success and survival rates of dental implants, there are several risk factors and complications that could lead to their ultimate failure.[1] Peri-implantitis is a progressive and irreversible disease of implant-surrounding hard and soft tissues and is accompanied by bone resorption, decreased osseointegration, increased pocket formation, and purulence.[2] The frequency of peri-implantitis has been reported in the range of 1%–19%.[3]

When left untreated, peri-implantitis may cause progressive tissue destruction, bone loss, esthetic complications, and, eventually, implant loss. Based on numerous clinical trials and systematic reviews, several approaches for implant decontamination are available. In the context of this nonsurgical mechanical debridement, surgical debridement, disinfection with chemotherapeutic agents, and smoothening of implant surface, laser therapy along with regenerative periodontal therapy should be noted.[4],[5],[6],[7],[8],[9] Mechanical debridement can be done with carbon, plastic or titanium curettes, ultrasonic scaling, or powder–air abrasion.[9]

When a titanium implant surface has been exposed to the oral cavity and contaminated with bacteria, implantoplasty to completely flatten/smooth the exposed part of the implant using rotary instruments may be indicated.[10] Initially recommended by Lang et al.[11] and reported by Suh et al.,[12] this technique aims to reduce the roughness of the titanium surface to decrease plaque adherence because it has been demonstrated that rough surfaces accumulate more plaque than smooth or moderately rough surfaces.[13],[14],[15] As implant decontamination is the key aspect to the resolution of peri-implantitis, different mechanical and chemical methods have been tested in that respect. Recently, a noticeable tendency has urged scientists toward the application of laser in order to decontaminate peri-implant inflamed area.[8],[16],[17]In-vitro models have proven the efficacy of erbium-doped yttrium aluminum garnet, carbon dioxide laser, and diode lasers in high or even complete elimination of bacterial-loaded titanium discs.[18],[19] Diode lasers, in particular, have been shown to have potent bactericidal and photobiomodulatory effects promoting wound healing and tissue regeneration.[20],[21]

Current evidence suggests that peri-implantitis does not respond to traditional nonsurgical therapy.[22] In addition, surgical therapy has been demonstrated to result in significantly reduced probing depth and gains in clinical attachment levels around the affected implants.[23] The aim of the present case report was to gain predictable results by detoxification of the implant body surfaces in a case with peri-implantitis.


  Case Report Top


A 38-year-old male patient reported to the department of prosthodontics and oral implantology with the chief complaint of persistent pus discharge from the sinus opening near to an implant placed in the lower left first molar region. The implant (Nobel Biocare RP, 4.3 × 10, Nobelpharma Canada Inc.) had been placed before 2 years in the same department. Treatment was started with antibiotics, namely tablet amoxicillin 500 mg t.i.d. and tablet metronidazole 400 mg b.i.d., for 7 days. The sinus tract was resolved, but, still the patient was complaining about sour taste and pus discharge from the same site in the morning. Hence, the patient was referred to the department of periodontology and oral implantology for the same. Pus discharge and sinus opening were absent at the time of presentation. On examination, peri-implant probing depth (Implacare Hu Friedy® PH 6 COLORVUE PROBE, Mfg. Co., LLC, Europe), 6 mm mesio-buccal, 5 mm disto-buccal, and 5 mm on the lingual aspect in relation to the implant placed in 36 region, was found [Figure 1] and [Figure 2]. Bleeding on probing (BOP) was present. A diagnosis of peri-implantitis was confirmed, with the patient's intraoral periapical (IOPA) of 36 region showing arc-shaped bone loss with three implant threads exposed [Figure 3]. Open flap debridement with implantoplasty, treatment with diode laser, and regenerative periodontal procedure were planned following patient consent for the treatment.
Figure 1: Preoperative peri-implant probing depth, mesio-buccal

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Figure 2: Preoperative peri-implant probing depth, disto-buccal

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Figure 3: Intraoral periapical of 36 region showing arc-shaped bone loss with three implant threads exposed

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Surgical procedure

Implant prosthesis was replaced with healing abutment. After achieving adequate local anesthesia (1:100,000 epinephrine), full-thickness mucoperiosteal flap was reflected following crevicular incisions in the adjacent interdental papillary region and the crestal incisions around the implant. Then, tissue debridement was done with metal curettes (Hu Friedy, Mfg. Co., LLC, Europe) [Figure 4] and [Figure 5]. Implantoplasty procedure was carried out with a diamond grit polishing bur [Figure 6] The peri-implant bony defect was thoroughly washed with normal saline [Figure 7]. Further, tissue laden with metal particles was cleaned with plastic curettes (Implacare, Hu Friedy) [Figure 8]. 808 ± 5 nm diode laser (DenMat Sapphire® Portable Diode laser, DenMat Holdings, LLC Lompoc, CA) aiming beam was moved in an apico-coronal and mesio-distal direction for 10 s at each site of the inflamed peri-implant bony crater-shaped defect (mesio-buccal, buccal, disto-buccal, and lingual) to implant. It was used at a power of 0.1 W, noncontact in a continuous wave mode on each site, for a total time of 30 s [Figure 9]. After presuturing bone graft (Perioglass®, NOVABONE products LLC, USA), placement was done [Figure 10]. Sutures were taken followed by periodontal dressing. Postoperative antibiotics, analgesics, and mouth rinse were prescribed. The patient was called for follow-up and suture removal after 10 days.
Figure 4: Removal of granulation tissue

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Figure 5: Saucer-shaped, peri-implant bony defect

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Figure 6: Implantoplasty procedure

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Figure 7: Peri-implant bony defect was thoroughly washed with normal saline after implantoplasty

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Figure 8: Peri-implant tissue laden with metal particles was cleaned with plastic curettes

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Figure 9: Irradiated peri-implant bone with diode laser low-level laser therapy

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Figure 10: Bone graft placement done

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After 3 months during re-evaluation, BOP was absent and peri-implant probing depths were measured 1 mm mesio-buccal, 1 mm disto-buccal, and 2 mm on the lingual aspect [Figure 11] and [Figure 12].
Figure 11: Postoperative peri-implant probing depth, mesio-buccal, after 3 months

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Figure 12: Postoperative peri-implant probing depth, lingual, after 3 months

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  Discussion Top


Human studies have shown that combining implant surface cleaning with mechanical methods such as curettes and saline-soaked cotton pellets contributes to obtaining clinically stable results up to 24 months.[24] An in-vitro study using a surface profilometer showed that metal curettes reduce the roughness of rough-surfaced implants and decrease the attachment of Streptococcus sanguinis which is an important early colonizer in the oral cavity.[25] Metallic curettes after 20 s of use can remove superficial material from the rough surface on an average of 0.83 μm compared to 0.19 μm removed by titanium curettes and ultrasonic tips covered with plastic inserts.[26] In the present case report, metal curettes had been used in open flap debridement around the implant.

The aim of implantoplasty is to produce a smooth and polished implant surface, thereby reducing the amount of dental plaque that attaches to it as well as removing the implant threads, providing a less attractive environment to bacteria.[27],[28]In-vitro studies have shown that the use of diamond polishing devices can remove the coating of the implant surface entirely, thus exposing the body of the fixture. There is no consensus about the type of bur to use for implantoplasty. An in-vivo study showed that diamond grit and carborundum polishing or just the carborundum gives similarly polished surfaces.[13],[29] The release of titanium particles from implant fixtures placed onto the peri-implant bone during preparation of the implant bed has been reported. In the present case report, the peri-implant region was thoroughly rinsed with saline during and after implantoplasty. To clean all the released titanium particle debris from the peri-implant bone surfaces, saline-soaked cotton pellets and plastic curettes were used to prevent scratching over the polished implant surface. Previous studies have shown that the released titanium particle debris is mainly concentrated at the crestal parts of the bone in contrast to the apical areas. Debris amounts reaching 0.2–3.0 mg may induce peri-implant osteolysis, which manifests as early marginal bone loss around the implant.[28],[30]

Diode lasers have a bactericidal effect due to a localized increase in temperature, which stimulates fibroblasts and osteoblasts,[31] which, in turn, causes increased production of RNA messengers, leading to significant collagen production during periodontal tissue healing.

Shortly after laser was invented in 1960, Mester et al. noticed photobiomodulatory effect of laser over mice. Low-level laser therapy with diode laser has an effect on fibroblasts by promoting proliferation and increasing cell numbers, secretion of growth factors, and differentiation of fibroblasts into myofibroblasts.[32] Various in-vitro studies have shown that laser irradiation increases basic fibroblast growth factor release from gingival fibroblasts.[33],[34] This collectively results in improved wound contraction and accelerated wound healing.[35],[36] However, a precisely determined dose has not been proved for each indication. Biostimulation has been reported in literature with doses between 0.001 J/cm2 and 10 J/cm2 as a therapeutic window.[37] Even though the applied dose is in the therapeutic window range, it might be too low or too high for the desired effect. Mester et al.[38] suggested in 1971 that doses of ≈1–2 J/cm2 are necessary to obtain an effect on wound healing. One randomized, split-mouth clinical trial showed the additional photobiomodulatory effect of 810-nm diode laser over modified Widman flap surgery in cases with chronic periodontitis; bone and root surfaces were irradiated at 0.1 W in continuous mode.[39]


  Conclusion Top


It can be stated with some assurance that physical alteration (smoothing) of the implant surface using metallic instruments has been demonstrated to slow or halt the progression of bone loss in humans as well as in animals. While this application is certainly useful, the drawbacks include soft-tissue retraction and esthetic compromises. At present, a combination of physical and chemical approaches possibly with appropriate laser therapy may prove to provide more predictable results. From this case report, it can be argued that further investigation of optimal ways to treat implants affected by peri-implantitis as well as the prevention of these problems is warranted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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